Nursing Interventions for BDD

Body Dysmorphic Disorder (BDD) is an under diagnosed and often misdiagnosed mental health condition due to the similarity of symptoms it shares with other psychiatric disorders including depression, anxiety, agoraphobia, social anxiety disorder and obsessive-compulsive disorder to name a few.

People who suffer from BDD believe there is something wrong with their physical appearance, usually concentrating on one “defect” such as their nose, skin, teeth or weight. The extreme discontent in their looks is not realistic, and arises from various psychological, biological and socio-cultural factors.

It would seem cosmetic intervention such as liposuction, dermatologic treatments, and even surgery would be an easy solution to the problem, but research has shown this form of treatment should be avoided. The problem is not physical, and usually after patients undergo any type of cosmetic intervention, they are either happy momentarily or not at all. They may then seek another practice or physician to have more cosmetic enhancement on that body part, or fixate and shift their attention to another body part altogether.

Patients are averting their anxiety, depression and negative emotions from their past and possibly present state onto their body as a way to heal themselves, which is why BDD is classified as a somatoform disorder.

Effective Treatment for BDD

Pharmacologically, Selective Serotonin Reuptake Inhibitors (SSRIs) have proven to effectively treat BDD. Phillips states SSRIs help patients control their preoccupations, obsessions and repetitive behaviors associated with their “defect.”4

Pavan et al. stated patients response to SSRIs also included a decrease in stress and an improvement in social and occupational functioning.Other medications that may help include anxiolytics and antipsychotics.10 A second form of effective treatment is cognitive behavioral therapy (also used to treat OCD). Crerand and his colleagues wrote that:

“Cognitive behavioral therapy involves the identification and modification of problematic, appearance-related cognitions and behaviors. Strategies used in cognitive behavioral therapy include self-monitoring of thoughts and behaviors related to appearance (e.g., monitoring the amount of time spent mirror gazing); cognitive techniques (e.g., challenging distorted thoughts about one’s appearance); and behavioral exercises (e.g., exposing the patient to a feared situation and preventing engagement in compulsive behaviors).”2

Obviously, BDD is a disorder that is characterized by a preoccupation with an imagined or slight defect in a person’s physical appearance, but the most effective treatment is not to physically enhance or alter that feature but to get help from pharmaceuticals or from trained psychologists and therapists.

Nurses’ Roles

It is crucial for nurses to learn the signs and symptoms of BDD and to be able to work with these patients to build their self-esteem and help them get the proper treatment.

As healthcare providers, nurses need to learn more about this disorder if they are working in the field, especially in cosmetic surgery, and therefore be effective in dealing and interacting with these types of patients. Most of the time, these individuals do not even realize they have the illness. By preventing people from undergoing cosmetic enhancement that suffer from BDD, we are preventing potential lawsuits by the clients and possibly any violence and harm to ourselves and fellow healthcare providers.

Also through intervention, nurses can help the patient to prevent undergoing unnecessary cosmetic surgery, prevent the development of further body issues, and be able to help effectively treat the disorder.

A common issue nurses and other healthcare professionals face is in helping the patients to become more realistic. In the patient interview, it is important nurses do the following:

·observe the patient with their complete attention (notice body language, facial expressions, does patient actively cover the flaw?),

· use questions effectively (open ended questions encourage the patient to give more detailed information regarding grooming rituals and habits),

· be an active listener (evaluate patient’s stress, paraphrase comments verbalized by the patient),

· know there is no quick fix.

Nurses as educators can help these patients learn more about their disorder in a non-aggressive and non-intimidating way. Always acknowledge there is a problem; telling these patients there is nothing wrong, or convincing patients their beliefs are untrue or irrational will make them feel as if you are discounting their experiences and feelings.

Nurses can explain to their patients they appear to have a body image problem known as BDD, that BDD is recognized in the medical field and is treatable, and many people suffer from it, as well as inform them that cosmetic treatments are usually ineffective.12


Part I

What is body dysmorphic disorder?

Part II

Do surgical interventions help these patients?

Other suggestions include: recommend reading material on BDD, educating family and friends where needed and applicable, and referring the patient to a psychiatrist for treatment with an SSRI. 13 If patients do not use the referrals, the nurses themselves can speak to the client and focus on the “large amount of time they spend obsessing about how they look, the amount of distress it is causing them, and how it is affecting and even ruining their life.” 12

As mentioned previously, cognitive behavioral therapy is effective in helping patients with BDD. The research done by Phillips and Dufresne acknowledge this as well, finding this type of therapy involves exposure and response techniques and prevention:

“Exposure consists of having patients expose the perceived defect in social situations (going to formerly avoided restaurants or stores without a hat or heavy makeup, or sitting in a crowded waiting room). Response prevention consists of helping patients avoid BDD behaviors, using techniques such as covering or removing mirrors, limiting grooming time, covering skin areas that are picked, and stopping makeup use and seeking reassurance.” 12

Nurses play a key role in this type of therapy in simply being there for the patients, providing them with reassurance and self-esteem. Once there is a well-established nurse-client relationship, these patients can feel comfortable with their nurse and be willing to express themselves, as well as feel more comfortable in their own skin. Therapy also helps patients with OCD because it helps to decrease some of their compulsive tendencies.

Simple, Effective Treatments

Patients with BDD are sometimes misdiagnosed as having social anxiety disorder because of their tendency to avoid social situations due to their insecurities with their perceived defect. Stefan G. Hofmann and Nina Heinrichs from the department of psychology at Boston University did a study regarding the effects of mirror manipulation on self-perception in patients with social phobia subtypes.14

The study consisted of 82 individuals with social phobia; half were asked to sit in front of a mirror for 5 minutes, and then after the 5 minutes were over, were given a sheet of paper and asked to record three positive and three negative characteristics to describe themselves. The mirror was still present during this task. The other half of the participants were given the same instructions without the presence of a mirror. (p. 134) Findings were the patients with mirror exposure had more positive and negative self statements about their bodily appearance, this concludes mirror exposure enhances public self awareness.

The importance of this study in nursing is that is serves as a way for nurses to help their patients enhance awareness of themselves and their “defect,” and possibly act as a helpful measure to raise their self-esteem and view themselves in a more positive light. The presence of a mirror, even temporarily, forces people to “correct their negative perception bias about private aspects of the self, concerning social situations, while it enhances public self consciousness.”14

A cost effective way for nurses to help their patients suffering from BDD to cope is to help promote exercise and physical activity. Patients with BDD often suffer from depression because they feel so overwhelmed and consumed with their physical appearance and it affects their everyday lives.

Research proves exercise is an effective treatment for patients suffering from depression. Studies done at Duke University show “30 minutes of brisk exercise 3 times a week is just as effective as drug therapy in relieving the symptoms of major depression in the short term, and also greatly reduces the chances of depression returning.”

Amy Morgan and Anthony Jorm published research regarding self-help interventions for depressive disorders and symptoms, they also found exercise to be an effective measure to help alleviate symptoms of depression.15 The exact mechanism by which exercise helps to alleviate symptoms of depression is unclear, but proposed mechanisms by Morgan and Jorm include: “Physiological factors, such as effects on sleep regulation or serotonin and endorphins. Proposed psychological mechanisms include the interruption of negative thoughts that may prolong or worsen depression, or an increase in perceived coping ability.”15

Exercise, therefore, serves as a free way for patients to try to help alleviate some of the sadness and distress they feel from their disorder, and nurses can serve as great motivators and educators to these patients. Many other interventions nurses can teach or offer to their patients that may help alleviate and treat depression and depression symptoms include: herbal remedies or dietary supplements, omega 3 fatty acids (fish oil), St. John’s wort, vitamins, CHO rich and protein poor foods may lift moods, autogenic training, bibliotherapy, distraction, meditation, humor, pets, prayer, yoga, aromatherapy, hydrotherapy, light therapy, massage, music, negative air ionization, and singing. 15

Happy Life Awaits

Body Dysmorphic Disorder is under recognized in the medical profession and healthcare professionals need to become more aware and educated regarding this psychiatric mental health issue.

With insight and knowledge into this disorder, nurses, doctors, and others can help identify patients with BDD, initiate effective treatment and slowly decrease the prevalence of patients undergoing cosmetic enhancements as a way to solve the perceived problem or defect. Researchers definitively agree upon the use of anti-depressants, specifically selective serotonin reuptake inhibitors (SSRI’s) in treating patients with BDD.


The Body Image Puzzle

Learn how to make body image assessment part of your nursing assessment. Read the article, then take the quiz for CE credit.

Even if the patient was not suffering from major depression, these drugs alleviated the symptoms of sadness in patients and help to lift their mood, which in turn affects their views of themselves and their imagined ugliness. Psychiatric therapy was also a major factor throughout the literature that was used in these patients to help alleviate and treat BDD.

Since most patients suffering from BDD in actuality do not have any real defect in their appearance, their disorder is more psychologically based and in their mind. Therefore, it is understandable why patients seeing a psychiatrist and a therapist respond with better treatment outcomes than those who undergo cosmetic intervention. Many of these patients deny they have a problem or deny they have psychiatric issues and so they turn to cosmetic intervention as what they believe will cure their insecurities and obsessions. The literature has clearly shown cosmetic intervention seldom treats these patients’ concerns about their physical appearance, and these patients often start dwelling on another body area.

The goal is to identify these patients as soon as possible, intervene early before they choose to undergo any cosmetic procedures, and help these patients recognize the need treatment from other sources such as psychiatry, therapy, pharmacological and non pharmacological intervention.

Most importantly, nurses need to affirm to patients there is indeed a problem because denial can make matters worse and will make them feel as if the feelings they undergo are not real or meaningful to the nurse.

These patients have a serious mental health disorder that can be effectively treated when healthcare professionals work together to guide the patient in the right direction to a happy and healthy life through education and intervention.

References for this article can be accessed here.

Valeria Dworkowitz graduated from Rutgers University in 2010. She is a staff nurse on the TBI unit at the Kessler Institute for Rehabilitation, West Orange, NJ.

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