Psychiatry & Psychotherapy Podcast - Body Dysmorphic Disorder: A Guide for Therapists and Mental Health Professionals with Dr. Katharine Phillips

Episode Date: September 8, 2023

Body dysmorphic disorder (BDD) remains one of the most intriguing yet under-acknowledged psychiatric conditions of our time. Characterized by an obsessive focus on perceived physical flaws or defects, often invisible to others, this disorder manifests in ways that can profoundly affect an individual's daily life, self-esteem, and overall well-being. Through an exploration of its origins, symptoms, and prevalent treatments, this article aims to equip mental health professionals with a comprehensive understanding of BDD. We also shed light on the invaluable contributions of renowned experts in the field, most notably Dr. Katharine Phillips, whose pioneering research and clinical practices have transformed the way we approach, diagnose, and treat this complex condition. As the quest for insight and effective interventions continues, understanding BDD becomes pivotal for therapists and clinicians dedicated to holistic patient care. Financial Disclosure for Katharine A. Phillips, M.D. Fabday LLC (presentation for providers of aesthetic treatment, honorarium) CeraVe/Roxane S. Chabot DBA RBC Consultants (psychodermatology advisory board, honorarium) By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome to the psychiatry and psychotherapy podcast. I'm your host, David Puter. This is your gateway to the intriguing world of mental health. As one listener put it, this is the podcast that your psychiatrist listens to. And we're incredibly proud of that endorsement. Whether you're a loyal, active listener who's been kind enough to reach out, maybe send an email at DM or put in a review, or you're new to this community. We have an exceptional opportunity for you, not only to learn, but to also, earn continued medical education credits with each episode. Our credits are meticulously designed to empower you in your field, demystify complex mental health topics, and transform your learning journey into a truly rewarding experience. To access this and more, just visit Psychiatrypodcast.com. We're grateful to our valued subscribers who are already reaping the benefits of these credits. Your support is instrumental in allowing us to devote time each week to curate. this podcast, sharing cutting-edge insights, featuring top professionals, and exploring the latest

research. Whether you're here to learn, earn credits, or both, we're thrilled to have you with us. Get ready to deepen your understanding of psychiatry and psychotherapy, one enlightening episode at a time. All right, welcome back to the podcast. I am joined today with Dr. Catherine Phillips. She is a renowned psychiatrist who has been doing pioneering work in body dysmorphic disorder for over three decades. She is a professor of psychiatry at New York Presbyterian and while Cornell University in New York. She has over 350 publications, 11 books, one of the groundbreaking books on body dysmorphia. And so my audience often says, Dr. Peter, please do something on. body dysmorphic disorder and I was trying to figure out who's the expert I want to interview on

this and we've been corresponding by email so it's good to finally get you on here. So welcome to the podcast. Thank you. Thank you. Thank you so much for inviting me. I love talking on this topic and just really delighted to be your guest today. Thank you. Okay, so maybe start by giving like a definition just so people are kind of understanding what we're talking about today. Sure. So body dismorphic Body dysmorphic disorder, which is abbreviated BDD, sometimes referred to as body dysmorphia, is a common and often severe mental disorder in which people become obsessed with the idea that something's wrong with how they look, that their skin is terribly scarred, their nose is misshapen, they're going bald, it can be any part of the body. In reality, these are people who look normal. and the perceived flaw, the flaw that they perceive isn't visible to other people or it's only slight and not anything they notice unless you pointed out to them and they, I guess maybe you're, you know, this is a little crooked like most people's, right? But not obvious to others, but the person with body dysmorphic disorder thinks it's very obvious to other people. They have distorted body image.

And then in addition, they're preoccupied with this. So they think about. about it a lot. They worry about it a lot. At least an hour a day, on average, three to eight hours a day, obsessing. I hate, you know, my hair looks so ugly. I need a chin implant. I look really bad. And again, they look normal in the eyes of others. And then very importantly, an important part of the definition is that the preoccupation with these perceived defects in your own physical appearance must cause significant emotional distress. So that might be anxiety, depression, a whole range of negative emotions. Or it must cause clinically significant impairment in day-to-day functioning. So maybe making it harder to go out and do things and be around people because you think

you look bad. You don't want to see people. It's harder to concentrate. Maybe you don't do as well at work or at school. and because you have these obsessive thoughts that are crowding your mind. And that last part of the definition, that the preoccupation must cause significant distress or impairment in function is very important because it helps us differentiate the disorder, body dysmorphic disorder,

which needs treatment from more normal appearance concerns, which most people have at some point, at one point or another. Most people have some concern, oh, I have a Zit today, that doesn't look great. Oh, you know, I don't, you know, this isn't the best hairstyle. Or, you know, those are very common kinds of worries that people have. And tell me like, okay, so you said three to eight hours a day. On average.

On average. Like what, what is going on during that three to eight hours? They're thinking they're thinking they look bad and these intrusive thoughts coming to their mind. And they're thinking people are going to. to think I'm ugly. I look ugly. My hair's not right. My neck looks weird. It can be any part of the body. Sometimes you're thinking, I need surgery. Often while they're having these thoughts, they're also performing repetitive behaviors. The repetitive behaviors are triggered by the thoughts. The thoughts are very upsetting, certainly, to people. No one wants to think there's

something really wrong with how they look and that everyone else notices that. So when you have these thoughts, you want to check how you look and try and fix how you look. Maybe you're going to check the mirror. That's a very common repetitive behavior. Start comparing with other people. How do I look compared to them? And so not uncommonly, they're doing some of these repetitive behaviors, maybe fixing their hair, maybe working on their makeup while they're having the thoughts.

I think for diagnosis, we usually require at least an hour a day of having these negative thoughts if you add up all the time you spend throughout the day, it's an average of about three to eight hours a day obsessing about these perceived flaws. For some people, it's every waking minute. Some people even have nightmares about it at night. Some people can never, never escape these thoughts, these very distressing, very upsetting thoughts. So the intensity almost seems it just seems so painful. It seems such so much agony. Yes.

And it seems like there's an overlap with OCD, how OCD presents. How is this different? Or do you kind of think that it's similar? Maybe you could speak to that a little bit. Great question. So body dysmorphic disorder is both similar to obsessive disorder and different from it. So it's related disorder. And it's classified in the same chapter,

with OCD in BSM-5. It's similar in the sense that people have these intrusive, unwanted, distressing thoughts that triggered compulsive behaviors. So, of course, the content is different. In OCD, you might worry about getting contaminated with dirt or germs and watch your hands a lot, or worry the house is going to burn down if you don't check the stove 30 times, and so you go check the stove 30 times. And BDD, it's always about appearance.

and thinking you look wrong, something's wrong with how you look. And then the repetitive behaviors are excessive mirror checking, excessive grooming, sometimes skin picking, trying to make your skin look better, asking other people, how do I look? Do I look okay? So in terms of the obsessions and the compulsive behaviors, similar. But there's some important differences between body dysmorphic disorder and OCD. One is the people with BDD tend to be more depressed and have more severe depression. they are more often suicidal.

And that's a very important thing to keep in mind. If you're working with people with BDD, you always have to assess suicidality because it's common. It's probably BDD is more likely to be associated with a substance use disorder. There's a lot of self-medication of distress in BDD, the distress of thinking you look really ugly. And one important, another important difference is insight. So most people with OCD, if you ask them, they have pretty good insight.

They, if they think, for example, the house will burn down if they don't check the stove 30 times possible, with OCD, say, well, I don't really think that's going to happen. I'm just afraid it might, right? So I just have to check the stove 30 times, just in case, you know, before I leave you. BDD, they're much more likely to think that their belief is true, that they really do look abnormal or ugly in some way. And I think that contributes, you know, that may be one reason, you know, it seems to be more distressing. And it's probably because they actually see something different. They have perceptual abnormalities. They're seeing the world differently than people without BDD do.

And so they're kind of believing what they're seeing, but what they're seeing isn't accurate. But that poor insight is important clinically because it can be harder to get people with BDD. to accept mental health treatment. It would be harder to keep them in treatment. A lot of them want cosmetic procedures instead, which almost never improve the symptoms. Yeah, yeah, I'm curious, like, how do they usually present to your clinic

or how do they find a normal? So maybe, I mean, you as a specialist, I imagine you attract a certain type of person, but then is how do they normally present? like what kind of pain points lead them to say, okay, I'm finally going to seek mental health treatment? Well, some people do wonder if they might have body dysmorphic disorder. Often they're not sure. They think they probably don't.

But sometimes they'll say, well, I know I check mirrors a lot. And I'm worrying about my appearance a lot. So maybe I have BDD, even though they think they probably really do look ugly even though they don't. So sometimes people have, I guess, a little bit of insight and they'll come for treatment. Sometimes it's because they're very depressed. and they want help for their depression. Often the depression is due caused by the suffering that BD causes. A lot of my patients are brought by somebody else who realizes that they probably have BD.

I just saw a young woman this morning, 17-year-old, whose mother brought her because her daughter wanted a rhinoplast nose job. The daughter didn't think she had BD and she thinks she really needs as a horrible nose, which she doesn't. So I think a lot of people are brought by someone else who has read about body dysmorphic disorder, heard about it, and thinks that their family member may have it. Okay. So I'm just curious, like someone like that comes in, you're having this initial conversation with a 17-year-old. How do you, does that person by the end of the session have some insight that maybe she has body dysmorphia? I wish I had a magic wand. I impose insight over a couple of hours. I hope that some people do develop somewhat better insight in one consultation in our initial meeting.

I do explain that people with BDD see themselves differently than others see them. I tell them a little bit of just a little bit about the brain imaging studies. that have been done that show that. And I mostly, you know, I think one thing I'd say is it doesn't work to try to talk someone out of their belief, right? Especially if they're completely certain that they look abnormal, what we would call delusional beliefs or absent insight. It doesn't work to talk them out of those thoughts, just as doesn't work, talk someone's

schizophrenia out of the delusion. But we talk to just have maybe open their mind a bit to the possibility, you know, and that maybe others see them differently than they see themselves. They see themselves much more negatively than others do, differently than others do. And I think what can help is to really focus in on their suffering and the impact of their appearance, concerns on their functioning and quality of life, because that's something everyone can agree on.

So I think talking about, about that, that this is really, they're not enjoying their life. They're not living their best life, the life they would like, and that we have great treatments that can really get them there. We have excellent treatments,

and, you know, would they be willing to give them a try? And then we talk about, you know, what those treatments are. And a lot of people are willing to give them a try, which is wonderful because they usually, if they're given correctly,

they usually work. They work for most patients. Okay, so how many years after someone started to have symptoms does it take for them to get treatment usually? Yeah, probably about 15 years, something like that. It might be less now. That date is from a while ago. It might be less now because BDD is so much better known than it used to be.

I mean, when I started my work on BDD, clinical work, seeing patients, research studies back in the early 1990, maybe he was unknown, which was, you know, it had been described around the world for more than 100 years, and I'm sure it's been around longer than that, but there had been no systematic research studies.

It had fallen through the cracks of modern day, psychiatry, knowing about it. And I hadn't heard about it in medical school and my residency, but it's really gotten so much better known. And actually, it's quite well known these days on social media, and by the public.

And so I think that's really helped to rate, you know, there's so much more awareness now. And the media has been so helpful with that because, you know, just doing the kind of interview I'm doing with you right now has done so much to raise awareness about BED and it's not simply vanity or a phase that adolescents go through, that we have good treatments.

So I hope that it doesn't take an average of 15 years anymore for people to get treatment. I would say that most of the patients I see these days haven't delay that long. I see a lot of young people who haven't had it maybe for a few years or five years or sometimes longer. But I think people are probably accessing treatment earlier on average. But unfortunately, sure, there are people. We know there are people who never get treatment or who delay for a very long time. Do you think that, or do you often see people who have been through plastic surgery and multiple

plastic surgeries. How often, is that the presenting thing? Like, hey, I've had 10 surgeries. I'm still obsessing. That's common. So in my research studies, I've learned that about three quarters of people with BDD have sought cosmetic procedures and about two-thirds actually receive at least one. And sometimes they do a fair amount of doctor shopping for that or provider shopping because sometimes they are turned down because they look normal or often quite attractive. And so a majority get cosmetic treatment. And in only about 5% of cases is cosmetic treatment helpful for BDD. And it makes sense because BDD is not a problem with your actual appearance, right?

It's a problem body image, how you see yourself. And so changing a surface characteristic, like getting a rhinoplasty and changing the shape of your nose, doesn't change the person's tendency to zero in on minor aberrations or even nothing that is visible, something that's not even visible to anyone else to obsess about it. So, yeah, it's very common for people to have had these procedures. They're virtually never pleased with the outcome.

They can be very risky. Some people find that their symptoms, their sessions get a whole lot worse after cosmetic treatments. And many have had multiple treatments. I saw one beautiful young woman. She was about 25 and I think she'd had, I can't remember the number, 25 to 50 cosmetic procedures. Lots of rhinoplasties and all kinds of things done to her. and we treated her with medication and cognitive behavioral therapy. She never had another seizure.

She didn't want it because she got better. That's, yeah, I'm just wondering at one point, is that like almost malpractice for a plastic surgeon to continue? You know, it's interesting that you say that because the American Academy of, otolaryngology, the ear, nose and throat specialists who do, some of whom do rhinoplasties, put out a practice guideline for the field, for their members, saying that rhinoplasti and someone with body dysmorphic disorder is contraindicated. It's the strongest word we have

in the field of medicine for, do not ever do this, right? Because the outcome is often poor, the patient often suffers more. Sometimes the surgeon gets threatened. physically attacked. Yeah. There's a survey done of cosmetic surgeons, 265, those cosmetic surgeons, and asked if they had seen patients with BDP. Of course, they probably all have, right?

But they miss it in their, you know, they think they're picking up on it, and sometimes they do, but they also miss it more that they miss the diagnosis more than they realize. But 40% of them, 40% of those who said they had operated on a patient with BDD, 40% said that they had been threatened legally, physically or both legally and physically by someone with body disorder. And it's just reflex to how distressing this disorder is for people who have it, that these cosmetic treatment, as best we know, does not help. And we don't, we never recommend it. the person I saw today came to me because she wanted a rhinoplasty and her mother didn't know what to do.

And, you know, I said we never recommend cosmetic procedures. And rhinoplasty, and those jobs might be the riskiest. We don't know for sure, but that may be the case in terms of a poor outcome. Being really unhappy with the outcome. Oh, okay. Because it could get worse. Yeah, I mean, because they're so in tune to minor details. will probably look that they may say this isn't this what the surgeon did isn't what I wanted or there's still a little bump over here or it's still not perfectly symmetrical or now you know

the tip looks a little too turned up or you know you got rid of the bump but you took off too much or because their brains are are too good at seeing detail and they pick up on it all all these teeny details other people wouldn't even notice. And then they tend to obsess about little things they see. So yeah, it's really common to be disappointed with the outcome of cosmetic procedures. And that includes dermatologic procedures.

Dermatologic treatment is even more common in surgery because the skin is the number one group of concern followed by hair concerns, which dermatologists often address. So maybe, 40% of people have had thermontologic treatment, maybe depends on the study, 20 to 40% have had cosmetic surgery for BED concerns. So that's very common. How did you get into this? Like, what's the, like, when did you start to get interested in this?

You said you hadn't heard about it during medical school. No. Residency. No, because it wasn't on the map. You know, people, it didn't have any lectures on it. No one, no one talked about it. I started, I saw some patients with BDD when I was still in my training when I was in my third years, my psychiatry residency. And I remember seeing one young man in particular doing, I did an evaluation. He was very, very depressed. He couldn't work because he was so depressed. He was pretty suicidal.

And I, you know, at the end of the appointment, he's walking out my door. And then he turned around. His hands actually on the door handle and he turns around and he said, should I tell you the real reason I'm here? Yes, please do. He came back and it was because of his hair. That's why he was depressed. That's why he couldn't work.

That's why he felt like. And his hair was entirely normal. He had a lovely hair, you know. And so I saw a few patients like that. And I saw how much they were suffering. and I thought, why haven't we heard, why haven't I heard about this? Why has no one, no, I'm not aware of this. These are people who are really suffering.

And I went, I saw, and they were getting this diagnosed. I saw a patient who'd been hospitalized on the inpatient unit where I worked for six months with the diagnosis of schizophrenia, not getting better. He actually had been eating. So I decided I have to learn about this. What is this? And we didn't have the internet back then, so I went to the library and found every published article I could find. I found articles from around the world, Japan, Russia, you know, every continent

and my supervisors and people at the hospital translated all these articles for me. And I wrote a published a review article on it in the American Journal of Psychiatry. And so, you know, it was clearly. something that caused a lot of suffering to describe for a long time. But as I said early, we had almost no good research studies. We don't even know what all the symptoms were. We didn't know what the comorbidities were. We didn't have any ways to diagnose it. We didn't, you know, we didn't have screening measures. We had no treatments. So I just decided, I have to figure this out. This is something important that I want to try to to figure.

figure out and do something about. So I started, this has been my life's journey and I've started, I started with the basics and just talking with patients and listening to them, listening to their stories and gathering data on their symptoms and what portion had depression, how many were suicidal. And I just gathered all this information and then developed scales so we could diagnose it, screened forward, assess the severity, assessment site, moved on to treatment studies. So I've done medication studies, therapy studies, gotten a lot of grants along the way because all this takes funding, right? And seeing patients throughout because I really like treating patients,

and they taught me most of what I know. But I think it was just, you know, an overlooked source of a lot of suffering. And suicides, unfortunately. That's amazing. So it started really with that kind of just, I'm going to find every little article I can and then wrote a review on it. Yes. And then you created a measure.

And then you kept treating people and kept thinking about what treatments work. Yeah. And you've written a book on cognitive behavioral therapy. Yeah. For body dysmorphic disorder. Yeah, many books on body dysmorphic disorder. Yeah, because I always wanted to get the word out to the public, right? And clinicians too, because they didn't really know about it.

Yeah, and it seems like if you didn't know about it and you're just seeing someone who's suicidal, and we see a lot of people who are suicidal, and you didn't realize, like, well, what came before the suicidal thoughts, right? And so what you're saying is potentially in this client, what we'll find is that the obsessiveness about something about their body preceded, the depression and the suicidal thoughts. It seems to actually trigger it. And then triggers it. Many people have said to me, if you look like a monster and some will use a term like that, not everyone.

Some will just say, I'm unattractive, some will say ugly, that's probably the most common term. Some will say, if you looked as bad as I do, and you thought everyone was looking at you and making fun of you, wouldn't you be too? So the thoughts themselves are very distressing and can trigger or precipitate depression and certainly suicidal thinking. We found that about 80% of people with BDD have had suicidal ideation at some point in their life.

About 25% have actually attempted suicide. And we don't have, well, let me just say there have been a number of studies that suggest that BDD might be the psychiatric disorder that is most often associated with suicidal ideation and suicide attempts. It was recently a fairly big study about 500 patients at McLean Hospital, in their partial hospital setting, where they found that BDD was more highly associated with suicidality than more highly associated than depression, major depressive disorder, bipolar depression, PTSD, OCD, you know, so.

What about like borderline per size disorder, body dysmorphic disorder? Is there an overlap? How big is the overlap? Yeah, so BDD can be comorbid with any psychiatric disorder, including personality disorders. Most often major progressive disorder, followed by substance use disorders. It depends on the study and the study population, but anywhere from 40% of patients, with BD to 100% have a comorbid personality disorder. I think that really it's probably more in about the 50 to 60% range.

But the most common is avoidant personality disorder. Now, the challenge there is that sometimes it's hard to disentangle the effects of BDD from avoidant personality disorder, right? Because BDD makes people socially anxious and avoiding it. They don't want people to see them. They feel very self-conscious. They feel they stand out in a crowd in a negative way. And so sometimes it's very hard to figure out, you know, is this social avoidance is really, is it just a symptom of BDD or is it an anxiety just, you know, or is it avoiding personality disorder?

And border personality disorder is more common in people with BDD than in the general population. But I'm trying to recall what we found, I don't know, it's maybe 5% of people with BDD have comorbid borderline personality disorder. So it's not a lot, but certainly any co-occurring personality. disorder, especially borderline, can complicate treatment and make treatment more difficult, more challenging. But one thing to mention is that in the early days especially, I hope not anymore, BDD was just assumed to be vanity. We now know it's a brain-based disorder, and we've got wonderful, well-done, showing that. NERD out on the brain science studies. Can you summarize that? That means there for us.

BDD was just thought to be vanity, and it was trivialized, and no one thought it was important, and some people thought, oh, this is just narcissistic personality disorder. And it's, you know, yeah, most, it's only a very small percentage of people of BDD have narcissistic personality disorder. Most people with BDD do not want to look unusually beautiful. They just want to look normal and not look ugly. So to get to your question, yeah, the brain studies are really, really interesting and some are extremely well done of a whole variety of studies have shown that people

the brains of people with BDD are too tuned into detail and you can even which makes sense because when they look at themselves they're seeing teeny little things that other people wouldn't notice and their brains have trouble with something called holistic visual processing seeing the big picture is this a building what is you know what what what what what am i is it a house is it a barn you know just they have trouble with the big picture so the deep but their brains are too good at seeing detail and so you know the details take over what they see so when they look at themselves they they glum on their brain globs on to some little detail and they have hard their brain has a hard time contextualizing that and seeing it's just a teeny little or maybe even nothing

it all. And to them, it becomes this really awful, disgusting-looking thing, whether it's a pimple on their face or whether it's a slight unevenness of their eyes or, you know, whatever it is that they don't like. And you can see evidence of this on brain scans, on functional MRI scans, where compared to healthy controls, if they're in an fMRI scanner, looking at photos while they're in the scanner, the brains of the people with BDD compared to the healthy controls, the parts of the brain that see detail are kind of hyperactive. So their brains are trying to pull detail out of what they're seeing,

even from fuzzy photos where there are really no details to see. And the part of the brain back in the occipital lobe in the back of the brain that specializes in seeing the big picture of what you're looking at, is underactive. So again, the details take over what they're seeing. And I think this explains why they're just, they're so certain that they don't look right because they're actually seeing themselves differently

than we see them. So this also, the similar visual processing abnormalities and anorexia and nervosa, but they're more severe in B2D. So that that's probably the basis of the body image distortion and why so many people with BDD are certain that what they're seeing is abnormal, you know, doesn't look right because they're actually seeing something different than other people are seeing.

Wow, that is fascinating. Yeah, and it helps you have some empathy that there's this kind of like hyper focus on the small details in a way that maybe you haven't ever had, if you are someone who has suffered from this. And it can be so hard for family members and friends to understand. What do you mean you think you look ugly? You look lovely. You're so attractive.

And the person with BDD just can't understand that. Right? And it can even lead to arguments, fights to say, you know, people just have, there are these two different perspectives, right? And that's why it doesn't help to try to convince someone. Oh, you're very attractive, you know, because many people with BDD are. just trying to convince them of that doesn't really work because they're not seeing that. Do you see this, like what's the ratio of male to female?

It's about 60% female. And so some people assume it's almost all female, you know, but men get it too, definitely. And in some studies, there's even a higher proportion of men. And I should mention, you know, a form of BDV that happens almost exclusively in men, like to hear about that. I think I saw your Amazon book on that. Oh yes, yes, you've done it's right. Is that what you're going to talk about or something else? Well, we talk in that book, we talk about a range of body image concerns in men, right? Feeding generally eating disorders in men, but we also talk about a specific form of body dysmorphic disorder that occurs

almost exclusively in boys in men, which is muscle dysmorphia. And these people with the muscle dysmorphia think they're small and puny, body bills too small. And in reality, they look normal or sometimes they're massively muscular because a lot of them abuse cannibal steroids, which are quite dangerous. But they do build muscle, right? Yeah, I've seen like men who, unlike YouTube clips and stuff, where they're talking about how they need to get this a little bit bigger and they're at these massive bodybuilders, right? And it's like, yeah, I just feel like this bicep isn't quite as big and, you know, as it needs to be. And so you're saying that it can be more global, like a musculature, like, that they're

obsessed about it in a very unhealthy way. It's not about, because on my podcast, I talk a lot about, like, the value of fitness, not for aesthetics, but for health and for mental health, right? But what you're saying is that there's a group of people where it's like, it's beyond, non-aesthetics, or it is solely aesthetics. Tell me more about this. Like what, have the, do these people come in to see you? Or is this like, that's a great question. I think not as often. Yeah. Well, with other, you know, BDD more generally. Yeah. So, so these could be like attractive males.

Yes. That have good body, you know, muscles. You look at them, they're probably very attractive. But you're saying in their mind, they could be super obsessive about. not being quite there. Yeah, thinking there's too scrawny and thin and, you know, and they want to be very muscular. But remember to qualify for diagnosis of BDD and muscle dysmorphia is just a type of BDD.

It has to, they have to be preoccupied with this, at least an hour a day, obsessing about it, and it has to either cause them a lot of, you know, significant distress or interfere with their day-to-day functioning. But, yeah, this is a form of BDD that's, I think, especially worrisome because it seems to be associated with higher rates of suicidal thinking,

higher rates of substance abuse, and I think it's a little bit more challenging to treat. Now, a lot of these men also have other parts of their body, too. That's kind of typical. But, yeah, they can lift weights compulsively. I've had patients who, they had to lift constantly. One worked as a dishwasher

and he was so driven to build muscle that he was lifting huge stacks of dishes and he'd run into the bathroom with big stacks of dishes and just because he had to keep he was so distressed by thinking he was so small and of course he was actually very muscular.

A guy who was in his basement all day just lifting weights, furniture if there weren't any weights around and he actually damaged his body. He was maybe about 40, and he had to be in a wheelchair because he had done so much lifting that he had really done a lot of damage to himself.

And the antibiotic steroids, it's different than steroids you might take for asthma or something, right? These are the type of steroids that build muscle. They get them illegally and usually, and they're really potentially very dangerous, especially if you inject them. And a lot of these men use a lot of other drugs.

Human growth hormone. Oh, yes. All sorts of things. Bivoid meds. I saw a patient who was taking literally 50, 50 drugs. 50? Yeah, his kidneys shut from it.

Oh, incredible. Fortunately, when he came to see me, his kidneys had recovered. I'm happy to say. but yeah it's I think it's it's a form of BDD that sometimes is overlooked that does affect disproportionate almost all more occasional women but yeah I think I think that there's a big it's such a culture now where you look at people online too and if you're a young guy or a young girl like you have no idea what these people are doing they could be spending like these guys

There was this one guy, you know, he professed that he just ate liver, you know, like animal livers, liver king. And it was found out that he was lying for years. And it was like $30,000 worth of chemicals he was putting into his body every month, you know? But people look at that. And then it's like, how does that inform how they view themselves? right and I'm wondering yeah is is this getting worse with social media in your mind or like have you seen any studies where it's like you know it's it's it's not it's different right as it progresses as we progress with like TikTok and video and how does that change this as well a great question you

know BDD currently affects about two to three percent of the population so that makes it more common than OCD, more common than anorexia, schizophrenia, etc. The last good nationwide prevalence study was done in 2015. That was eight years ago. We don't really know, and that study, though, did find a higher prevalence than prior studies. Now, was it because of social media? A little bit higher? Was it because of the influence of social media?

Was it just difference in methodology of the study? I don't know. We don't have any good recent population-based studies to tell us if the prevalence is going prevalence is much higher in cosmetic treatment settings as you can imagine. But studies have shown that certain forms of social media, we can guess what types of social media. They're very image-centric. They're focused on appearance, beauty, fixing yourself.

But using certain forms of social media does seem to be associated with and maybe cause work. body image. But body image is a much bigger bucket than BDD. That's just a big, broad term, right? Most of us, as I said earlier, most of us dislike something about how we look and a lot of people don't have great body image.

But that's a little different than the disorder BPD. There's only one small study of BPD showing an association with use of certain form, image-centric forms of social media. It might have been Facebook and maybe Snapchat or something. which is one small study and association of course doesn't mean causality because I mean maybe use of image-centric social media does increase, maybe it's one more risk factor

for BDD getting it. But on the other hand, people with BDD are more likely to go online and start comparing themselves and morphing themselves and filtering themselves and all that. And that can be one of the BDD rituals. So we don't have science to really give us that answer about BDD. But my sense is it is a risk factor and not the only cause of BDD because BDD was around, has been described since the 1800s. We know it's about 40 to

50 percent genetically determined. So BDD results from many different factors. There's not one thing, not one reason that someone gets BDD. But I do think that use of certain types of certain forms of social media is probably one more risk factor. And, you know, it may just push people over the edge into BDD who are already at heightened risk of getting BDD. We don't know how big a role it's playing, but I do think it's playing a role, and it may be increasing the prevalence of BDD. So it makes sense this patient I saw this morning.

You know, she's talking about, you know, she really, it was when she was checking on social media that she really started thinking, I need rhinoplasty, right? She's a lovely, beautiful young woman. did not need but comparing herself and and also you know I think certain forms of social media

have really made cosmetic procedures much more acceptable in our society and I don't I don't see cosmetic procedures as inherently good or bad we just know they're not good for people but I think that

they they normalize it to you know social media can normalize these kinds of procedures and then they make people with bddd want them more than they used to want them but people with bdd have always wanted cosmetic procedures so that's not really that's not really new but is social media making it worse i suspect so when you okay so he said 45 to 50 percent genetic um what do we know any of the other environmental factors that are like what preceded it You know, was there like parents that talked about, you know, body parts or was there, you know, what have you found?

We have some clues, but we don't really know if it's just an association or if some of these things resulted from the BDD or they're actually causal. don't really know. But some might be cause, might be so-called environmental, non-genetic perspective. So what is people with BDD tend to report that they've been teased more than people without BDD

earlier in life, teased about their appearance, teased about competence. And that kind of makes sense that if you're teased, that may make you more self-conscious, especially if you're teased about your appearance. they tend to be somewhat, oh, there's also some evidence that there's a higher rate of abuse or neglect earlier in life than there is an OCD, for example, more compared to norms for the general population.

You know, so we don't know that that's causal, but that might make some sense, too, because you're abused, you're neglected. it's not very good for your self-esteem. And especially if, you know, and especially if you add that with being teased about how you look, sometimes people will say, oh, you know, people were, you know, kids teased me about my nose or my, you know, my stomach was sticking out.

So, you know, that might be a risk factor for BDD. It makes sense in some such. would support that. I did. In one study, I found that people of BDD were more likely to report low parental warmth when they were younger, but we don't have a way of actually confirming that. But I remember one of one of my patients many decades ago said, you know, I always felt like the run to the litter.

I always felt I wasn't good enough. and you know that that is low self-esteem perhaps a risk factor for getting big ed could be many things and there's a lot we don't know about risk factors certainly cultural factors societal factors our society probably does seem to be getting more and more appearance focused so just to say briefly you know one thing we do in therapy hopefully we'll get to talk a bit about treatment but one thing we do in therapy is to help people value other aspects of themselves other than how they look. And some people, this is more anecdotal. I don't have, there are no studies on this, but some people now, I think this is just a

minority, said that they were always very attractive and got of a lot of attention for that. And they became too important a source of their sense of self-worth and self-esteem. And then as they got older, you know, people didn't necessarily constantly come up to them and say, oh, you're so, what a beautiful child. Oh, you're so attractive, right? And partly it's because that's not so much what happens when you're an adult. People do that more with kids.

But so I think for some, probably a small proportion, they were very cute or attractive as children. and that may have led them to overvalue physical appearance. And then as an adult, they develop these visual processing problems and they're not being complimented frequently about how they look. You could see possibly a risk factor for getting BDD. Okay, one other study, or one study that I looked at, you looked at the Big Five, the Neo, which I've done episodes on, and you've,

oh, okay, you looked specifically at the high trait neuroticism. Yes, I'm glad you mentioned this. You want to talk about, like, is everyone with BDD high neuroticism, or was it just the people who are high neuroticism who are more difficult to treat?

Oh, no, it was BDD on average. So we just gave the neo to 100 people. I can't remember how many, and we've given other personality scales, temperament scales. And yeah, they scored quite high on average on neuroticism. They scored low on extroversion, so they tend to be more introverted. And a little low on agreeableness.

We don't know, and a little low on conscientiousness, if I remember correctly. So we don't know, though, whether these personality traits, and this is compared to norms on the measures. But it's not everyone. It's just these are average scores. So we don't know, though, whether these personality traits preceded the development of BDD and might be risk factors for developing BDD, which makes sense that neuroticism, you know, and feelings traits of anxiety and shame and self-consciousness and depressions.

We could see how that could be disposed to getting BDD. Or do they actually, do these traits actually result from BDD? Or do they just co-occur with BDD? We just don't know because we don't have any. we don't have any longitudinal studies of high-risk groups who you follow along over years and decades and see who gets BDB and who doesn't. So we don't really know, you know,

if those traits presuppose BDB. But I'll say with good treatment, those traits often get better. So what we think of as unchangeable parts of your personality really can get better, we found that in our medication step, one of my medication steps, actually. And then, you know, we've done other, there have been some other studies of personality traits showing low levels of assertiveness, high rejection sensitivity, both for appearance and more generally.

But again, do these traits predisposed to getting BDD, or are they just resulting from BDD or neither or both? Or we don't really know. Yeah. Okay. So, yeah, let's talk about the treatment because this is, I think this is really important. When you see a patient like this, how do you start to think about how you're going to talk to them about treatment and what treatments you're going to decide or start with?

Like, what's your go-to? Do you have like... First, I just try to connect with them. Okay, yeah. No, we have... Of course, we know the importance of empathy and the therapeutic alliance with every patient we see regardless of diagnosis,

but I think it's even more important for people with BDD because a lot of them don't really want to be seeing us or they're very embarrassed and shamed and they may feel very anxious about talking about their symptoms. So we know from studies that BDD is usually missed in clinical practice. So one thing I really have to mention is you really have to look for it, you have to screen for it. And it's pretty straightforward.

You just ask, you know, for a session, you know, when you ask about a variety of symptoms, you know, are you very worried about your appearance in any way? or are you unhappy with how you look or you can even normalize it a bit by some people are unhappy with how they look is that a problem for you and and of course you don't say what do you mean you look great you're beautiful you approach it as you would with any other symptom that patients mentioned ask them to you more about it go through the diagnostic criteria and then you have to give them hope about the treatment because a lot of them are quite hopeless and feel how can you help me

I have a problem with my jaw. I have a problem with my stomach, my thighs. How can a mental health professional help? So you have to do a little psychoeducation about BD, and I do explain what it is, and that it's common. They're not alone. It's treatable. Most people get better with the right treatment.

Tell them a little bit about the visual processing problems. And then, you know, I just offer them a lot of hope about treatment and just ask, are you willing to give it a try? we have two great treatments and they both work for majority of people. Are you just willing to give this a try? You're suffering so much. And really, as I said earlier, try to connect with them around their suffering and the negative impact of their symptoms on quality of life.

Just ask them to try. Now, with medication, you know, are they willing to give a serotonary uptake inhibitor a good three-month try, getting up to a high enough dose, which we can talk about, because we often need hypnosis. Are they willing to try cognitive behavioral therapy and commit to it and really give it a try? Why not? What's the downside? There really no major downsides of either treatment.

SRIs are usually very well tolerated. Only about 4% of patients in one of my big studies of Lexopro had to stop the medicine because of side effects, 4 out of 100. We know CBT takes work and commitment. but, you know, there's people tend to do very well with both of those, both of these treatments. So I just try to encourage them to give the treatments a try. Sometimes we do a little bit, we need a little bit of more formal motivational interviewing with patients and to try and get them motivated to at least try.

And if you're going to try, give it a good try. So you don't look back later and say, oh, that didn't work, but I didn't really give it a good try. So how to earn you know if it might? So. Yeah, okay, okay. So let's like, let's say they're like, yes, I'm willing to do both. Okay. You know, I think for mild BDD, I often, you know, and for more moderate, mild moderate,

you can choose. Do you want cognitive behavioral therapy? Now you have to find a therapist who knows how to do it. We'll talk about the specific treatment, hopefully in a minute or two. But you have a choice between meds and therapy. And, you know, as you know, serotonomy uptake in him, are usually very well tolerated, not-addicting medicines can help a whole variety of symptoms. So the more symptoms and disorders they have, they could get better with just one medicine,

the more I tend to lean towards the medication. But I think people have a choice, meds, or therapy for mild, moderate BDD. For severe BDD, I always recommend both. And for suicidal patients, especially, I always recommend both. they have they really have to take a seroton reptilian reptilian inhibitor i really because you know bd leads to suicide and probably at a very high rate and these medications can be can be life-saving so okay and and you said potentially high doses because when i think oCD i think high doses usually and i'm curious um so okay like lexapro acetalopram like what's a what's a normal dose well that one's

a little tricky because my average is about 40 milligrams a day. Now, the FDA maximum is very low for acetalopram lexapyam lexapro compared to the other SRIs. It's out of whack. So that's double the FDA max, but the max FDA maximum for most of the SRIs are not written in stone, right? And so do you start, do you start with 10? Do you start with 20? Like, and then wait? Yeah, that's over 10. With an adolescent, a younger adolescent, maybe, I don't know, be any adolescent. I would probably start with five. And maybe with an older person,

where you might be a little more concerned about, you know, tolerability, I might start five, but usually start with 10. And then after a couple weeks, I go up to 20. And then after a couple weeks, I go up to 30. And then I will keep it there. So they have a total trial of 12 weeks. And then we see how they're doing.

And then if they're not really well, I will gradually further increase the dose. Now, if they're starting to get better at 10 or 20, you don't necessarily go up to 30, right? You just might keep it at that lower dose longer and see if they keep getting better or better because not everyone needs to go up to a high dose. But for acetalopram, my average is around 40 for,

I use a fair amount of, I use a lot of fluoxetine prozac. Okay. My average dose is probably 80. So I go up to 120 for that. And certainly it's good. I will go up to 400. It's a great OCD study showing 400 works better than 200 if you don't respond to a good trial of 200 milligrams of soul off the day.

Okay. And I'll tolerate it. And so for those of you listening who don't know what these doses are, this is about twice or even three times what, you know, a normal outpatient provider would be like used to giving. Well, you know, it depends. I don't know. Like, I don't. Some people get better with 40 of Prozac, for example, occasionally 20.

You know, so there's a rain. You know, some people, I say most, you know, for Prozac, most people need 40 to 120. And the FDA max, again, not running stone. You can't exceed it. And people can do just fine is 80. So with Prozac will go up to 50% higher than the FDA max with ZolaF. I'll double it if I need to. But not everyone knows those high doses.

On average, though, the doses are higher than we would often use for depression or anxiety. But I often use those doses for those sorts too, and they often help and are well tolerated. So for Lusopro, though, at higher doses, you need to check in Phaegis, like 40 and higher is what I do. And I don't exceed the FDA maximum versus talopramal, or for chlamypheromene, which I don't use as often. Anaphymine. Anaphernal. Yeah. Do you use...

Those are hard stops, those maximum doses. Okay. And for like an Afrono-Klymopramine, do you use that if they don't respond to the SSRI? Exactly. I'll try a couple SSRIs first, and I'll do some augmentate ad. If they're not sufficient, you know,

add in some other meds sometimes. Okay, so what are you like... For OCD. After a couple SSRIs, often, you know, you'll try some augmentation, then you'll probably try Clement. What are your go-to? Like, what's your go-to?

your first med you might consider for augmentation? You can add something in because you optimize the SSRI dose. That's why I always do that first, assuming it's well tolerated, which it usually is. It depends. I think if their symptoms aren't that severe, I'll add vespam. Fuspar, anti-anxiety med, but it's not habit forming. And, you know, especially if they're more anxious and their symptoms aren't that severe, it's so well tolerated, almost no one has side effects.

It's a nice medicine to add maybe up to 30 to 60 or sometimes 80 milligrams a day. 80. I'm probably around 50. Yeah. Per day total dose. What's that? Per day total dose? Yeah, but I'll get there gradually.

I'll get there gradually. For people with more severe symptoms, I often will use aeropipid result. People who not necessarily more severe BDD symptoms because SRI's work as well alone, SRI's a loan work as well for severe obesity is mildly. But if they have co-occurring severe depression, suicidality that I'm worried about, maybe a lot of hostility and potentially aggressive behavior, Araprizole, you know, is often, adding that in is often extremely helpful. And with some patients who are very, very ill, who I'm very concerned about,

I think when I was worried that they're high risk in terms of BDD, depression, suicidality, I sometimes will start off with both an SSRI and aeropipazole abilify from the beginning of treatment. Sometimes I use both from the very beginning. Okay. And what doses for the aeropazole to usually? I started baby dose. I start with one milligram a day. Oh, yeah.

I don't want people to get side effects, right? So I'll spend one milligram a day for a couple of days, then we'll go up to two milligrams a day. And then the rate of titration depends on tolerability and, you know, how severe their symptoms are and how they're responding. I can get up, I don't know, maybe in the five to ten range or something like that. Okay. It's higher sometimes lower. And we have to be aware, of course, of the potential side effects with the atypical neuroleptics, like Abilify the boy, I have seen some miraculous responses and they can be very helpful. Okay.

So, like, let's say they have been taking a medication for a while, they decided to get off. Is BDD just going to come back? Or do you see that there's less BDD? Yeah. A really good study. Good question. Because when I think of OCD, I think if they get off, the OCD is probably going to come back. Well, it depends on the study.

The relapse rates vary a lot across different studies. Yeah, please tell me what you. Yeah, and in BDD we have only one relapse prevention study, which I did and with a colleague. And we found that among responders to estatalopram lexathrop, after a 14-week trial, we took the responders and randomized them to continue on the lexapro for another six months or switch over to placebo. It was double blind, so no one knew what they were getting. And after six months, about 40% had relapsed, not necessarily. as badly as when they started, right? Their symptoms weren't necessarily that severe.

But about 60% didn't. And so I think it's hard to say. You know, it's hard. Some people relapse and some don't. We usually treat for longer than six months. I usually recommend three to four years at least of treatment. Most people want that because they feel so much better. And the SRIs are so well tolerated.

Most of them, the ones I tend to use, like crows happen so often, like the prep. But is the relapse rate different after you've been on them for three to four years? I don't know. Maybe it's lower. I'm not sure. There are some people who, I think there are some people, though, for whom I recommend lifelong treatment. People with a lot of, you know, concerned suicide attempts or maybe even one concerning suicide attempt, people who've stopped the medicine and relapsed every time, you know, when they have stopped it. So people thought, you know, multiple hospitalizations for BDD. I just recommend, I just recommend they stay on medications over the longer term.

And that's a choice even for less severe BDD. Some people offer that. I've been treating some patients for, you know, close to 35 years on SRIs doing just great. No side effects. Their mood's better. Their anxiety is better because SRIs, as you know, treats so many symptoms to be well tolerated. Okay. So I'm very grateful we have this.

amazing class of medications. And what type of remission rates are you seeing with... We found, and we looked at, only one study has looked at remission, meaning virtually no symptoms or none at all. We found in our Lexapro study of 100 patients that after 14 weeks, 25% had no symptoms at all of BDD, or virtually no symptoms, with only 14 weeks of Lexopro, 30 milligrams a day. So that's kind of amazing.

And then over the following six months, they tended to get better, better, better. Mm, okay. And so people often do get even better over time. And what about like the reduction and the amount of time obsessing? How does that change? Oh, yes, yes. That's what we see.

We see that the frequency and intensity of obsessions goes down. Hopefully the obsessions will disappear completely. the urge to do those repetitive behaviors, the hairstyling, the grooming, the mirror checking, carrying, skin picking, those urges get, you know, just diminish and people get more control over those behaviors. We want, hopefully, to go away completely.

Distress over how the person looks, decreases. It gets easier to go out and be around other people. There's a lot of social avoidance in BEDB because you think you look ugly. You think people are, often people think that people believe you think other people are staring at and maybe laughing it, making fun of them. So there's a lot of social avoidance. It just gets easier to go out and be around people and enjoy your life. And then depression tends to improve. Anxiety tends to improve as

well. So I always try to go for no symptoms at all. You know, I get there eventually with a lot of people. But some people end up with just very minor residual symptoms that aren't a problem in their life. And I just never give up. I just keep trying things. Sometimes I'll use a glutamate modulator, like a supplement, NAC, and acetylcyt, add that into an SRI. There are other things you can try with meds. And then cognitive behavioral therapies is our other very, very effective treatment. Yeah, let's talk about that. How is CBT for body dysmorphic disorder different than regular CBT, or is it? Well, it has some similarities and some differences.

I think the general approach is similar. It's a structured treatment. You focus on changing cognitions and giving people more control over their behaviors. But it's different from all, you know, CBT, as you know, has to always be tailored to the individual problem, the individual disorder. And so CBT for body dysmorphic disorder has some things in similar with. with CBT for OCD, and it's quite different in some ways. So the main similarity is we do ritual prevention. That's so important.

We give people tools to tap back on all those repetitive behaviors. The mirror checking in particular, I think, is especially toxic. People can spend hours a day staring at themselves in the mirror from close up. And I wonder if that actually worsens their perceptual distortions, So if they're actually training their brain on wood to be more sensitive to tinier things, right? Tinyer little irregularities. So anyway, we give people tools to stop those repetitive behaviors. So refer to as ritual prevention or response prevention, just like OCD.

We do exposure therapy, help give people tools to go out and not stay. Because some people get housebound. They won't leave their bedroom. Not everybody. There is a range of severity in BEDD, and I need to emphasize that, although on average, BD is pretty severe.

But we help people feel more comfortable going out and socializing. Maybe they're not dating because they have BED and they're too self-conscious and think no one would want to go out with them. So we work on that. Maybe they're cut off from their friends because they feel too self-conscious and ugly and too uncomfortable. So we help people give them tools to go out and do more. things and feel more comfortable.

And a very important part of the treatment is the cognitive treatment where we help people, we do cognitive restructuring, where we help people learn about cognitive errors. Like there's a lot of mind reading and BED. Oh, that guy must be thinking I look really horrible. There's a lot of truth telling. If I go to that party tonight, everyone's going to be thinking how ugly I will. How can I possibly even be here? Fortune telling, mind reading, catastrophizing.

So people learn all these cognitive errors and we help them develop more accurate ways of thinking. We also do some body image work and not staring in the mirror. We want to keep people, we want people to stop staring in the mirror and stop checking the mirror. It's just about a five-minute daily exercise where we try to help them to develop a bigger picture of view of themselves. because when people with BDD look in the mirror, they tend to zero in on the things they hate, and that's sort of all they see, right? And we try and help them appreciate that there's more to them than just the top of their lip, if that's what they don't like, or the height of their forehead, if that's what they don't like,

and help them develop a more accurate view of themselves. We also do some self-esteem work using some cognitive therapy approaches. I think that's very important. As I said earlier, help people develop a broader sense of self-esteem. None of us is simply what we look like. We all have personality traits. We all have talents and abilities.

And so we help people try to identify and appreciate aspects of themselves, positive aspects of themselves, that they've really been ignoring. So they developed a more balanced, healthier self-esteem. If they want cosmetic treatment, we focus on that in treatment, try and help them think that through and hopefully not get it or at least delay it until after they've had one of these recommended treatments, the serotonal re-take inhibitors or the CET.

And sometimes we need some motivational interviewing to help people really get engaged in the treatment. homework is really important, you know, practicing those skills. I'll say to patients, you know, if you're a softball player and, you know, you're not going to become good at it if you simply just go once a week, you go to practice and that's all you ever play.

Not going to get all that good. If you're a guitar player, you're not going to get very good. If you just go to one lesson in a week, you've got to practice, right? And it's the same thing. And what I love about it is people learn to become their own therapist, basically. We want you, We want people to practice these skills for the rest of their life, even after they stop formal CBD.

And I should mention there are two therapist manuals, guides for doing cognitive behavioral therapy with BDD. I think it can be hard to do without a manual to follow a guide. And one is, and I mentioned two, there are increasing number of books out there on how to treat BDD. But I mentioned these two because they've been shown in research studies. you know, they've shown the treatment to work. So one is a therapist manual by,

I'm one of the authors on it. The first author is Sabina Wilhelm. It's at Harvard. I'm an author in Gail Steckady. It's an author, and we have tested this treatment and published this treatment. It's online at Amazon. And the other is by David Veal and Fuggen-Nezeroglu,

who also tested their cognitive behavioral therapy. And there's a treatment manual available. for therapists that they published also. So there are a couple guides out there to follow. Excellent. Yeah. I will link those in the article

that will go with this episode. Along with all your other books, I mean, some of your published studies, you are truly prolific and I don't know how you do so much. It's like incredible. Well, you know,

it's, yeah, I've been very passionate about this. It's, when you really get a sense of how much these people suffer, and it's not vanity, it's a serious illness, can you get to suicide, you know, that's been very, very motivating. I wanted to figure it out because how was it that we didn't know about this? We did not have treatment. So the field has come a very long way.

And we have other good researchers in the field now, and so we're learning a lot, a lot about it. That's exciting. It's like for people with this disorder. Yeah, and kind of wrapping things up, is there anything, any pearls that kind of are still floating around in your head that you want to make sure people hear? Yeah, just look for body dysmorphic disorder because it is more common than people think. It's easily missed because patients are often embarrassed and shamed and, you know, I want to talk about it, screen for it. Just ask, are you worried about how you look?

It's that simple. The diagnosis is usually quite straightforward. we have great treatments. Meds and CBT work for majority of people. If you dose the meds right, right, then choose the right, choose an SRI as your first line med. And the CBT can be very, very helpful. And most patients really do well with treatments. So look for it and ask about it.

And look for some of the clues, right? If someone comes in with their hair over their eyes or they really want to ask about BDD, because we didn't talk about camouflaging. They all try to hide what they don't like. If they seem to get stuck in the bathroom in your office, you want to ask what they're doing in there. It's a fair therapist. You can ask these questions.

And, you know, were they checking themselves in the mirror? Are they worried about their appearance? You should at least ask. Social avoidance. Don't assume it's social anxiety disorder. It might be BDD. School refusal. Don't assume it's just school refusal.

Maybe they're not going because they think they're too ugly or they're too obsessed and they can't begin to focus on their studies. So you want to keep in mind that, keep some of these clues in mind, if someone's picking their skin, has a lot of skin lesions, maybe it's skin picking disorder, maybe it's BDD, and they're picking because they think their skin doesn't look good, and they're trying to fix it. So you want to be aware of all these various clues and ask everyone.

Fantastic. I really, really appreciate you coming on, spending the time to educate the audience. And I think other people having listened to this will appreciate it as well. So thank you so much for your time, Dr. Phillips. And yeah, maybe, I don't know, maybe someone will reach out to you who want some help or love to have you probably come back in the future and help us continue to learn about this. I have a website people can visit and I'd be happy to come back anytime.

Awesome. Thank you. Thank you for having me today. Thank you so much.