Re: question about BDD

[Guest guest]

Hi Grace: Chelle, age 15, has been picking at her skin for quite some time. Once she starts, she doesn't stop until the last pore is squeezed. She has hundreds of small scars all over her face, neck, chest, shoulders, tops of her arms, and back. She rarely wears anything that is sleeveless and covers her face with makeup thinking that no one can see what she's done to herself. She usually picks at the mirror in the bathroom prior to getting a shower. A couple of years ago, she used to pick and scratch at her arms and legs, and then scratch open the wounds to make them bleed again. When she was doing that, she usually would wear long pants, even in hot weather. When the kids at school took notice, they called her Scabie. She told them she had poison ivy. While she was into that behavior, she was also picking at me--trying to pick any scab I might have or trying to pick off moles or freckles. It took a long time to make her keep her hands to herself. She was doing all this while we were spending time going to therapists who had no idea how to treat her TS, ADHD & OCD, etc. She's been pulling body hair for at least four years, and for a while even shaving her arms. She obsesses about the hair on her legs. She will not wear a skirt unless she shaves, even if she shaved yesterday -- someone will see the hair. The former therapist did not identify any this as Trichotillomania. She, of course, tried to find what I've been doing to Chelle to make her want to do this!! Perhaps the removal of her body hair was a sign that she didn't want to grow up and face the adult world. This reasoning because she (Chelle) saw it a difficult place since I'm a single mom, struggling to fill the void left by an absent father, a piddling amount of child support, while working, parenting,and having no social life, etc. Hair pulling could be a deliberate choice of Chelle's so she could remain a child or at least have her body appear child-like. Never once did this professional suggest that perhaps we should go to someone else where the appropriate therapy would be used to address my child's problems; that perhaps this was beyond her scope of expertise. We've been through Wrap Around services, again with a therapist who had no idea how to treat OCD. I feel like we have wasted so much time. I think it would have been so much easier to do E & RP therapy when she was 9 or 10, when it could have been more of a game. I, as you do, sometimes have difficulty trying to understand what is causing a particular behavior and what tactic to use to diffuse or change the behavior. Its heartbreaking to see our beautiful children mutilate and disfigure themselves and to not have an immediate solution to make it better. Wasn't it so much easier when they were 2 years old and we could magically kiss the boo-boos away? Thank you all for your help--I'm getting stronger. Pray for strength and guidance. Phyllis

question about BDD

I believe my 13 yr oldd has symptoms of BDD (body dysmorphic disorder)about her skin 9and in general insecure about her appearance). This is a spectrum of OCD in that the individual obbsesses about a flaw (real or imagined) in appearance and then takes compulsive or ritualistic measures to reduce the anxiety generated by the distorted thought regarding the flaw. The obsession can be like an intrusive thought ("I look grotesque"),the compulsions can be constant mirror checking, grooming, and comparing oneself with others. Also irrational (ocd like) is having a distorted perception of the flaw (ex: a blemish or scar makes one look monstrous or grotesque and not fit to appear in public). Also ocd-like is the waxing and waning. She has at times thought she looked fine, even with some blemishes.One of the ER & P methods is to not look in the mirror and to have the individual appear in public without hiding or disguising the perceived flaw. A cognitive method is to relabel the distorted thought ("this is not a major physical flaw, it is BDD thinking")kind of like saying "that is ocd thinking" in order to boss back.Getting to my question, another symptom of BDD is skin picking, especially facial, in an effort to improve appearance or remove the blemish or flaw. Obviously, this noticeably worsens the appearance. This is where I am confused, how can I suggest that my daughter's belief about her appearance is distorted when she has really altered her appearance in a noticeable way, which could admittedly require make-up? Initially her belief that a minor few blemishes were horrific was distorted, but now (off and on-she relapses) it is more than something minor. She believes that she cannot go out without "making up" and in fact, persons who saw her might indeed think she looks strange without make-up, in that she has wounds on her forehead (not to mention her eyebrows are not very visible from over-plucking). How do we do ER & P then, and how can she "restructure" her "distorted" thoughts when they are not really so irrational now?The only thing I can think of is to remind her that some people have large facial birthmarks or actual terrible burn scars etc and still go out. Appearing in public would eventually desensitize them to the anxiety about others' reactions. But with my daughter there is the big element of shame, because it was not an accident that causes the scarring, so she has something to hide that is not just physical, and she can't explain it like someone does an accident. This disorder at the same time seems like trichotillomania, due to the compulsive, maybe even self calming and at times not fully aware picking habit (though I think at other times she is very focused on the habit, in the bathroom at the mirror) and the resulting shame/embarrassment. With trich, I've learned that people try to accept themselves with the noticeable flaw (hair loss) and tell themselves that it is not their fault, it does not matter what others think, they are still good persons, and it is the trich to blame. So I could suggest this approach to my daughter. Also, I do think habit reversal can work for the compulsive aspect of picking, but am confused about the concurrent ocd-like part of BDD(intrusive thoughts/anxiety). Do we treat it like ocd with ER & P or like trich with habit reversal and self acceptance, or both? The therapist does not have enough of a grasp of it yet, I think, or the E & P would make more sense. So how to make ER & P and cognitive "relabeling" effective since my daughter could easily say that her perception (that she looks noticeably flawed) is true and since she will not,as a result, go out without make-up. Sorry this is so long-trying to formulate a treatment before school starts. GraceYou may subscribe to the OCD-L by emailing listserv@... . In the body of your message write: subscribe OCD-L your name. You may subscribe to the Parents of Adults with OCD List at parentsofadultswithOCD-subscribe . You may subscribe to the OCD and Homeschooling List at ocdandhomeschooling-subscribe . You may change your subscription format or access the files, bookmarks, and archives for our list at . Our list advisors are Tamar Chansky, Ph.D., Aureen Pinto Wagner, Ph.D., and Dan Geller, M.D. Our list moderators are Birkhan, Kathy Hammes, Jule Monnens, Gail Pesses, Kathy , and Jackie Stout. Subscription issues or suggestions may be addressed to Louis Harkins, list owner, at lharkins@... .

[Guest guest]

Hi Phyllis,

I am sorry that your former therapy was so off the mark. Your

daughter's urges sounds more severe than mine (my daughter confined

the urges to her face-though I wonder now about the shaving, she

requests new razors frequently, whereas I use my one razor on my legs

for a month or more). She wears make-up, but not long sleeves/pants.

Anyway, these urges are like a tic, it is not her fault, and the

therapist was sure unfair to suggest that it was yours, though a

stressful even can set it off- but we can't go through life

foreseeing and eliminating all stressful events can we?

BTW, did anyone see? Oprah had a segment yesterday about women who

never went without make-up, even to bed with it. They called it

vanity, but I think is BDD. The women agreed to go without make-up

and it caused extreme anxiety initially.

In my daughter's case anxiety/depression/panic was precipitated by

the last move, a final straw, I guess, after moving twice previously,

and also entering our Church middle school last year after

homeschooling, which seemed to feed into her appearance obsession (a

school full of " perfect " girls). I think she has always had social

anxiety and was easily overwhelmed or overstimulated even in desired

activities. Other than that we've had stable family life (though she

doesn't like the counter-cultural aspect of homeschooling and 5

children-part of her insecurity has to do with never wanting to

appear as " different " ). I've always had an awareness of anxiety

disorder due to my own family history, so wanted to offset what I

possibly could in how we structured our life. But could not do much

about the lay-offs and moving, or that my daughter percieves my ideas

of a happy family as an abberation (she doesn't know many kids with 4

younger siblings). Anyway, I think " dysfunction " is clearly not the

primary cause of ocd spectrums, rather the child's biological

predisposition is. There are so many families with stress, that do

not result in anxiety disorders.

Did your daughter ever have BDD? My daughter had BDD and social

anxiety before picking (obsessive about her looks and what her

classmates would think and awkward/apprehensive about fitting in). So

I think of BDD as primary,in a way, though I feel like the onset of

picking triggered something (a biochemical change?)that now makes the

picking urges more than just a response to her BDD. Or maybe going

back even further-social anxiety was primary. In the case of

picking, I think that biochemical " change " is what " trichsters' find

with their pulling as well, it starts as something benign like

removing a stray eyelash, and then an urge is triggered.

I am thinking now that we have to address the picking urge with habit

reversal first, before we address the " poor insight " of BDD. It is

still very convoluted to me since I see evidence of several anxieties-

social anxiety, BDD, trich, and even panic (attacks late at night on

school nights) maybe ocd " grooming " as well (needing hair just right,

needing to be very clean). I am trying to simplify it in my mind so

we can start treatment.

I found a website called " feelinggood.com " helpful with explanations

and examples of differing cognitive (to restructure negative habits

of thinking-such as relabeling) and behavioral (physical exposures to

anxiety etc) methods. Has anyone else viewed this site?

Grace

> Hi Grace: Chelle, age 15, has been picking at her skin for

quite some time. Once she starts, she doesn't stop until the last

pore is squeezed. She has hundreds of small scars all over her

face, neck, chest, shoulders, tops of her arms, and back. She rarely

wears anything that is sleeveless and covers her face with makeup

thinking that no one can see what she's done to herself. She

usually picks at the mirror in the bathroom prior to getting a

shower. A couple of years ago, she used to pick and scratch at her

arms and legs, and then scratch open the wounds to make them bleed

again. When she was doing that, she usually would wear long pants,

even in hot weather. When the kids at school took notice, they

called her Scabie. She told them she had poison ivy. While she was

into that behavior, she was also picking at me--trying to pick any

scab I might have or trying to pick off moles or freckles. It took a

long time to make her keep her hands to herself. She was doing all

this while we were spending time going to therapists who had no idea

how to treat her TS, ADHD & OCD, etc. She's been pulling body hair

for at least four years, and for a while even shaving her arms. She

obsesses about the hair on her legs. She will not wear a skirt

unless she shaves, even if she shaved yesterday -- someone will see

the hair. The former therapist did not identify any this as

Trichotillomania. She, of course, tried to find what I've been doing

to Chelle to make her want to do this!! Perhaps the removal of her

body hair was a sign that she didn't want to grow up and face the

adult world. This reasoning because she (Chelle) saw it a difficult

place since I'm a single mom, struggling to fill the void left by an

absent father, a piddling amount of child support, while working,

parenting,and having no social life, etc. Hair pulling could be a

deliberate choice of Chelle's so she could remain a child or at least

have her body appear child-like. Never once did this professional

suggest that perhaps we should go to someone else where the

appropriate therapy would be used to address my child's problems;

that perhaps this was beyond her scope of expertise. We've been

through Wrap Around services, again with a therapist who had no idea

how to treat OCD. I feel like we have wasted so much time. I think

it would have been so much easier to do E & RP therapy when she was 9

or 10, when it could have been more of a game. I, as you do,

sometimes have difficulty trying to understand what is causing a

particular behavior and what tactic to use to diffuse or change the

behavior. Its heartbreaking to see our beautiful children mutilate

and disfigure themselves and to not have an immediate solution to

make it better. Wasn't it so much easier when they were 2 years old

and we could magically kiss the boo-boos away? Thank you all for

your help--I'm getting stronger. Pray for strength and guidance.

Phyllis

> question about BDD

>

>

> I believe my 13 yr oldd has symptoms of BDD (body dysmorphic

disorder)

> about her skin 9and in general insecure about her appearance).

This

> is a spectrum of OCD in that the individual obbsesses about a

flaw

> (real or imagined) in appearance and then takes compulsive or

> ritualistic measures to reduce the anxiety generated by the

distorted

> thought regarding the flaw. The obsession can be like an

intrusive

> thought ( " I look grotesque " ),the compulsions can be constant

mirror

> checking, grooming, and comparing oneself with others. Also

> irrational (ocd like) is having a distorted perception of the

flaw

> (ex: a blemish or scar makes one look monstrous or grotesque and

not

> fit to appear in public). Also ocd-like is the waxing and waning.

She

> has at times thought she looked fine, even with some blemishes.

>

> One of the ER & P methods is to not look in the mirror and to have

the

> individual appear in public without hiding or disguising the

> perceived flaw. A cognitive method is to relabel the distorted

> thought ( " this is not a major physical flaw, it is BDD thinking " )

kind

> of like saying " that is ocd thinking " in order to boss back.

>

> Getting to my question, another symptom of BDD is skin picking,

> especially facial, in an effort to improve appearance or remove

the

> blemish or flaw. Obviously, this noticeably worsens the

appearance.

> This is where I am confused, how can I suggest that my daughter's

> belief about her appearance is distorted when she has really

altered

> her appearance in a noticeable way, which could admittedly

require

> make-up? Initially her belief that a minor few blemishes were

> horrific was distorted, but now (off and on-she relapses) it is

more

> than something minor. She believes that she cannot go out

> without " making up " and in fact, persons who saw her might indeed

> think she looks strange without make-up, in that she has wounds

on

> her forehead (not to mention her eyebrows are not very visible

from

> over-plucking). How do we do ER & P then, and how can

she " restructure "

> her " distorted " thoughts when they are not really so irrational

now?

>

> The only thing I can think of is to remind her that some people

have

> large facial birthmarks or actual terrible burn scars etc and

still

> go out. Appearing in public would eventually desensitize them to

the

> anxiety about others' reactions. But with my daughter there is

the

> big element of shame, because it was not an accident that causes

the

> scarring, so she has something to hide that is not just physical,

and

> she can't explain it like someone does an accident.

>

> This disorder at the same time seems like trichotillomania, due

to

> the compulsive, maybe even self calming and at times not fully

aware

> picking habit (though I think at other times she is very focused

on

> the habit, in the bathroom at the mirror) and the resulting

> shame/embarrassment. With trich, I've learned that people try to

> accept themselves with the noticeable flaw (hair loss) and tell

> themselves that it is not their fault, it does not matter what

others

> think, they are still good persons, and it is the trich to blame.

So

> I could suggest this approach to my daughter. Also, I do think

habit

> reversal can work for the compulsive aspect of picking, but am

> confused about the concurrent ocd-like part of BDD(intrusive

> thoughts/anxiety). Do we treat it like ocd with ER & P or like

trich

> with habit reversal and self acceptance, or both? The therapist

does

> not have enough of a grasp of it yet, I think, or the E & P would

make

> more sense. So how to make ER & P and cognitive " relabeling "

effective

> since my daughter could easily say that her perception (that she

> looks noticeably flawed) is true and since she will not,as a

result,

> go out without make-up.

> Sorry this is so long-trying to formulate a treatment before

school

> starts.

> Grace

>

>

>