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I had the good fortune to meet Scott Granet, author of Body Dysmorphic Disorder, Mine and Yours: A Personal and Clinical Perspective, at the 2023 OCD conference, where Granet facilitated a discussion group with the BDD community. I was absolutely captivated by his personal story and reached out to him to learn more about BDD. The following is a blog review as well as my personal takeaway from Granet’s incredible work of love.
Although the subject matter of Body dysmorphic disorder (BDD) is a very serious one, I could not put this book down. Scott Granet is vulnerable and brave as he shares his personal story of living with BDD. In reading this book, it is very clear that one of Granet’s aims is to save lives. Granet highlights the life-threatening nature of BDD by giving us an inside look into the internal world of a BDD sufferer. I get the impression that Granet has experienced for himself and with his clients, the dismissal and minimizing of others, who erroneously perceive BDD as a condition of vanity. This could not be further from the truth, as Granet shares with us that BDD sufferers often experience overwhelming self-loathing, perceiving themselves as monsters, freaks, and disgusting humans.
Prevalence of BDD:
BDD is really not rare at all, as it is considered more common than anorexia nervosa or schizophrenia. According to the International OCD Foundation’s separate website dedicated to BDD, it is estimated that as many as five to ten million people may have BDD (Phillips, 2020).
Other statistics obtained from Dr. Katherine Phillip’s 2005 book, The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder include the following:
1 in 8 people seeking outpatient treatment for social anxiety (now referred to as social phobia in the latest DSM 5-TR), also have BDD
1 in 8-11 people seeking treatment from a dermatologist are believed to have BDD
1 in 5-15 people who seek cosmetic surgery have BDD
What Has BDD Taken From You?
Our hair can often be a form of personal expression and creativity. I remember dying my hair a magenta color as a college freshman. This was my punk rock era where I also wore a metal studded belt. For those with BDD the freedom and lightness that can come with expressing ourselves through our appearance is unfortunately taken from them.
Granet reveals that he developed BDD at the age of 19. Unfortunately, due to the limited education and awareness of BDD at the time, it was not until age 30 that Granet started to notice his obsession with his hair was more significant than others. This realization prompted Granet to seek additional help, and received a referral to a psychiatrist, where he was diagnosed with depression, panic disorder, and phobia. He was also prescribed antidepressants and anti-anxiety meds such as benzodiazepines that Granet reports “knocked me out sufficiently so that I didn’t care about much else (Granet, 2021, p.12).” Unfortunately, Granet did not receive adequate psychoeducation at the time, that a common side effect of a benzodiazepine is the development of insomnia.
As a therapist myself, this personal account breaks my heart, that Granet’s suffering was compounded by misdiagnoses and a sleeping problem as a result of a benzodiazepine prescription by a trusted professional, which is now considered an ancient drug due to it’s addictive qualities.
What Constitutes BDD?
Granet wants his readers to know that “BDD is a very serious psychiatric illness with potentially life-threatening consequences. It is not about vanity or wanting to simply look better (Granet, 2021,p.23).”
Granet provides a history of the recognition of BDD as a mental health condition in 1986, in the 3rd Revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), where BDD was classified as a somatoform disorder. Somatoform meant that "the focus of the distress is connected to the body, though there is no known physical or medical basis for the symptoms (Granet, 2021, p.25).” The DSM, now in it’s 5th revised edition classifies BDD under Obsessive-Compulsive and Related Disorders due to the similarities BDD shares with OCD (Granet, 2021, p.25).
Other conditions in this category include excoriation (skin picking disorder), trichotillomania (hair pulling disorder), and hoarding disorder.
The Clinical definition of BDD, per the DSM 5-TR includes the following:
1. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
2. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his/her/their appearance with that of others) in response to concerns about one’s appearance. Typically, there is either nothing wrong observable to anyone else, or if there is something, it is slight and does not warrant the enormous concern being placed on it (Granet, 2021p.23).”
3. Preoccupation causes clinically significant distress in at least one important area of life, impacting functioning. Examples include compulsions such as mirror checking and grooming routines taking hours to perform, that impact work/school/other performance or functioning.
4. The preoccupation is not better explained by an eating disorder. If symptoms are best captured by that of an eating disorder, then an eating disorder diagnosis should be made instead. An eating disorder and body dysmorphic disorder can be present at the same time as well.
Muscle dysmorphia is a subtype of BDD, describing individuals who are overly concerned about their body build being too slight.
Lastly, there is an insight specifier to a BDD diagnosis. Insight refers to how much an individual truly believes there is a flaw in their appearance vs understanding that their beliefs are due to the disorder itself. Insight can range from delusional, poor, fair, and good. A therapy goal can include increasing level of insight (American Psychiatric Association (APA), 2022, pp.271-277; Granet, 2021).
The body parts that are most often identified by BDD sufferers tend to pertain to the head and face; however, any body part could become the focus of attention. Most common areas of concern for BDD sufferers include but are not limited to the following: the shape of one’s nose, hair on one’s scalp, facial skin, eyes, eyelids, wrinkles, ears, cheek-bones, lips, teeth, jaw, chest size, stomach, legs, hands, arms, hips, feet, toes, shoulders, buttocks, back, body hair, and penis. Did you know that on average, people with BDD report obsessing on over five body parts, not necessarily at the same time. Sometimes, just one body part will remain the focus. For others, they will notice that different body parts will be the focus of attention over time (Phillips, 2009, p.38).
Age of Onset and Other Co-Occurring Diagnoses and Components of BDD
The average age of onset for BDD is age 16 and BDD is known to impact males and females at about the same rate (2.5% in women; 2.2% in men) (Phillips, 2005, p.115).
Depression is often co-occurring with BDD, as a result of many aspects of BDD, such as isolation and hopelessness. With depression of course, suicidal thoughts are just one of the 9 symptoms associated with depression. It is believed that about 25% of BDD sufferers make suicide attempts (Phillips, 2009).
Other tragic components of BDD can include social isolation and self-mutilation. A person does not set out to self-mutilate, as this behavior is done with the intention of improving one’s appearance. Granet shares that he has known of individuals that engage in self-dental and orthodontic work, skin picking with either fingers or with utensils such as knives and tweezers, hair cutting, or using dangerous chemicals on the body (Granet, 2021, p34-35).
Let’s Talk About Compulsions
How does one best eliminate unwanted behavior, such as mental or physical compulsions? The answer is through eliminating reinforcement, meaning you eliminate any potential for immediate relief by stopping all compulsions, as in the case of Exposure and Response Prevention, where clients are encouraged to resist the urge to engage in compulsions.
Common compulsions associated with BDD include but are not limited to the following:
1. Mirror Checking
2. Comparing how perceived flawed body part compares to others
3. Touching/measuring the body part(s)
4. Overuse of beauty/skin care products
5. Grooming/hygiene rituals
6. Pursuit of dermatologic treatments, such as micro-dermabrasion, botox injections, etc.
7. Plastic surgery
8. Reassurance seeking
9. Camouflaging, which entails covering up the perceived flawed body part(s) partially or fully in some way, to prevent others from seeing it.
Exploring the Function of BDD
In meeting with the author, I learned that he truly is a master clinician, as his approach to treatment is to attend to the whole person. Living with BDD for 46 years has certainly granted our author an incredible perspective by which to conceptualize and treat BDD. Granet encourages clinicians and sufferers of BDD to ask what is truly being desired? “What do I want (Granet,2021, p.161)?” Granet shares that the answer often is happiness. He then encourages us to look outside of our bodies and body parts for satisfaction, peace, balance, and well-being. One of my favorite quotes from Granet’s book is the following: “we can’t use our body parts to give us a sense of well-being. They’re not meant for that (Granet, 2021,p.35).”
In Chapter 3, p.50, Granet provides a rare glance into his personal therapeutic experience as a client of a traditional psychodynamic therapist who would often sit behind him and offer interpretations. Although There was some usefulness to Granet’s psychoanalyst’s suggestion that Granet “wanted” the problem of BDD, I certainly believe there are more client-centered, collaborative, and more empathetic ways to get to the revelation Granet came to, which was “this wasn’t just about my not wanting to go bald, but rather the focus on my hair kept me from looking at other psychological issues that were likely causing me tremendous torment. This was the ultimate comb over. The more I paid attention to my hair, the less able I was to look at other, more important issues (Granet, 2021,p.50).”
I also agree with Granet regarding the possibility that someone’s focus on specific symptoms, such as those of BDD may serve an unconscious function of taking attention away from a larger problem, hurt, or unmet need. I often like to ask my clients the following question: “If I was not so consumed by_______,what would I then be the most worried about/hurt by/disappointed about?”
Also in Chapter 3, Granet explores the potential causes of BDD, suggesting that more research needs to be done regarding neurocognitive functioning, genetics, and the impact of trauma(s), including developmental trauma/complex PTSD as factors in the etiology and maintenance of BDD. Granet shares his opinion that the importance of ideology for BDD is different for that of OCD, which primarily benefits from exposure and response prevention, a form of cognitive behavioral therapy. This is where I would slightly disagree with our author , as I would also ask the following question to my clients with OCD: “if I was not consumed with this worry, what might I be worried about/hurt by/disappointed by…?” Although OCD treatment requires cognitive behavioral therapies such as ERP, I would also encourage clinicians to always assess and explore for trauma, as they can co-occur, and if that is the case, then treatment will be different and must include trauma treatment in addition to cognitive behavioral therapies, specifically ERP.
Recommended Treatment
In chapter 5, Granet highlights recommended treatment for BDD, that must include cognitive behavioral therapy. Specifically, Granet shares a message he has seen on a bumper sticker that captures the essence of cognitive therapy in particular, which is “Don’t believe everything you think! (Granet, 2021,p.69).” Granet summarizes the developer of Cognitive Therapy, Dr. Aaron T. Beck, highlighting how “our thoughts influence both our emotions and behaviors and can contribute to the maintenance of psychological distress if left unchallenged (Granet, 2021,p.70).” On page 73, Granet provides a very helpful example of an automatic thought record that he uses with his clients to help in identifying automatic negative thoughts, and a step-by step process of challenging such thoughts.
Granet highlights the essence of CBT in the following quote: “CBT is about learning how to reappraise your thoughts and situations in a more rational way. ERP is meant to drive home that point and to prove to yourself that your BDD thoughts are erroneous and can be altered (Granet, 2021, p.103).”
In chapter 8, Granet provides a glimpse into his work with an ambitious young adult female client, who’s goals included competing in the Olympics for track. I appreciate this story because it highlights two very important things. First, Granet shares that traditional CBT, including ERP was not sufficient for this client, which led him to seek additional resources, such as Acceptance and Commitment Therapy (ACT).
This seeking of resources is something a very good and caring clinician does. When looking for a therapist, this would be a great quality to look for; a clinician that is not stagnant in their learning, and eager to find better ways to help you reach your desired goals. The second message in this chapter can be highlighted by this quote “the gains she has made in her therapy so far have shown that her dreams may still be achievable. They just are going to take longer (Granet, 2021, p.119).” This is a difficult message to take in as a client. Managing BDD, and in addition also tolerating the distress and grief that comes with your vision of goals and timelines being altered, moved, or postponed is an incredible feat. This process can feel so defeating and helplessness can really kick in. This is where ACT is very helpful, as well as dialectical thinking, which is the ability to accept multiple things being true at the same time. An example of dialectical thinking is I have BDD and it is incredibly distressing and impactful in my life, AND I will still reach my goals. The following are also good examples: reaching my goals is possible AND reaching my goals will take more effort. ACT is helpful in guiding individuals to be accepting of the distress and difficulty that comes with mental health disorders, such as BDD, while also focusing on living a life consistent to one’s own personal values (Granet, 2021, p.119).
Recovery and Relapse Prevention Planning
Granet is humble and vulnerable as he shares what has helped him live the life he wants and deserves, while living with BDD. Granet bravely reveals that he has lived with BDD for 46 years and is not “cured.” He wants people to know that even with all of his knowledge and expertise, he still is triggered from time to time and can catch himself in a compulsion. The bright side seems to be that Granet has not experienced a major depressive episode in 15 years, in large part to his daily self-work.
Part of Granet’s recovery entails his absolute honesty with himself. He shares “If I look in mirrors for times other than grooming, then I’m checking. If I’m checking, then I’m giving BDD a perfect chance to cause trouble.” In this example, Granet shares he has an internal treatment plan regarding mirrors that he makes efforts to stick to.
Granet also shares his mindfulness about his top compulsions regarding his hair, which include patting/touching his hair to check for fullness, too much grooming, and comparing. With a mindful awareness, Granet shares he makes best efforts to continue to resist all compulsive behaviors. He shares he can find himself starting to engage in a compulsion, and luckily, with mindful awareness, he can pull away and disengage, removing the power from the compulsion.
Additionally, Granet shares his active work on checking in on himself emotionally. Granet states that in the past, “I was generally feeling good as long a my hair is good, I’m good.” Granet highlights that this is a “very artificial way of achieving some emotional well-being, and one that is bound to fail.” Essentially, Granet highlights that one of the functions BDD had was to ensure his emotional well being or satisfaction, at least for temporary moments. Now, Granet reveals he tunes into how he is feeling and allows himself to feel what he feels when he feels it rather than let BDD distract him from feeling uncomfortable emotions.
Granet also highlights that ACT has been instrumental in his recovery, making efforts to keep treasured pictures in his car as constant reminders of what he values most, his family, one of the many reasons to stay well. Lastly, Granet reveals that he embraces the fact that he is more than his hair, as he is a husband, father, son, brother, nephew, uncle, friend, therapist, teacher, and author. Incredible perspective to have, as it brings attention to what really enriches our lives.
Tips for Loved ones, Family Members, and Significant Others:
In Chapter 9, Granet exposes the tremendous emotional pain that loved ones experience, referring to loved ones as “silent sufferers,” revealing the terror that family members can experience in witnessing their loved ones battle with BDD. Granet captures the fear of loved ones in the following message: “you may feel woefully inadequate in your efforts to provide help and scared that one day your loved one may finally decide to end the battle and commit suicide (Granet, 2021, p.129).”
Granet encourages loved ones to learn as much as they can about BDD and to avoid engaging in any enabling behavior. Also, Granet encourages loved ones to hold those with BDD accountable for their responsibilities. For example, if a young adult is living with their parents, they are required/expected to participate in the maintenance of the household. This will encourage attention away from one’s body and to someone’s present day life, roles, and responsibilities.
The following are just some examples of topics covered in this chapter for loved ones:
1. Learn about BDD
2. Be compassionate while also setting limits
3. Do not Enable BDD
4. Family Life goes on
5. Considering Doing Your Own Therapy/Attending a Support Group
6. Limit or Eliminate The Giving of Reassurance
7. Don’t Ignore Siblings
8. Be mindful to avoid the blame game
9. Stay Patient With Therapy
10. Be an Exposure Therapy Coach
Relapse Prevention tips:
Granet shares that BDD is a lifelong illness and relapses can’t entirely be prevented; however, he does encourage others to have a game plan set in place to make relapses less likely, less intense, and less frequent.
Here are some tips Granet offers for Relapse Prevention:
1. Keep up the CBT strategies once formal therapy ends
2. Continue to take medication until you and your doctor have mutually agreed to discontinue it.
3. Consider booster sessions with your therapist.
4. Know your warning signs/Triggers
5. Don’t overlook stress management (p.139-140).
In closing, I want to thank Scott Granet for the time, effort, and bravery in writing this book, revisiting troubled times, and sharing his expertise and wisdom with us. Granet is a seasoned clinician and pioneer in the treatment of BDD.
Granet's book has inspired me to take a deeper dive into BDD, as it is more prevalent than I ever imagined. I feel this book has already helped me be more mindful and curious about our connections and relationships with our bodies, and the roles some of us expect our body parts to fulfill.
References:
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Granet, S. (2021). Body Dysmorphic Disorder, Mine and Yours: A Personal and Clinical Perspective. Toplight.
Phillips, K.A. (2020). Prevalence of BDD, International OCD Foundation. Https:// bdd.iocdf.org/professionals/prevalence/. In Granet, S.M. (2021). Body Dysmorphic Disorder, Mine and Yours (p.38). Toplight.
Phillips, K.A. (2009). The Broken-Mirror: Understanding and Treating Body Dysmorphic Disorder, Revised and Expanded Edition (p.38). Oxford University Press. In Granet, S.M. (2021). Body Dysmorphic Disorder, Mine and Yours (p.27). Toplight.
Resources:
The International OCD Foundation Website Dedicated to Body Dysmorphic Disorder:
The Body Dysmorphic Disorder Foundation:
The OCD-BDD Clinic Of Northern California, where you can find articles, links, and so many resources:
The TLC Foundation for Body Focused Repetitive Behaviors:
Article:
UNDERSTANDING THE ABCs OF BDD. Consulting Room | Volume 2: Issue 1 | Jan - Mar 2019, pp 42-45.
Assessments:
The Cosmetic Procedure Screening Questionnaire (COPS)
The Body Dysmorphic Disorder Questionnaire (BDDQ)
The Yale Brown Obsessive Compulsive Scale, Modified for Body Dysmorphic Disorder (BDD-YBOCS)
This Blog is written by Melissa Barsotti, LCSW, a private practice therapist specializing in complex trauma and dissociation, and OCD, in San Diego California.