Introduction to Narcissism and Eating Disorders, Volume 7, Issue 1
With the current issue of The Remuda Review, we continue our series of articles on common co-occurring problems faced by eating disorder patients. Throughout this series, we are considering the assessment, conceptualization, and treatment of self injurious behavior, anxiety disorders, mood disorders, substance use, trauma, personality disorders, and other co-occurring issues within Remuda’s bio-psycho-social-spiritual model. In each article, we consider how these co-occurring issues relate to eating disorder development, symptoms, and maintenance, and, where relevant, variable manifestations based on age, development, and culture.
The present issue focuses in depth on our ninth topic: narcissism and eating disorders. In our experience, a surprisingly large percentage of patients with eating disorders have narcissistic issues. Yet full-blown narcissistic personality disorder is rarely diagnosed in those with eating disorders. This may lead to a lack of clinician awareness of the subtler forms of narcissistic wounding in eating disorder patients. Such wounding greatly complicates eating disorder treatment, and, if not recognized, will often lead to power struggles with patients and premature termination of treatment. As such, there is a clear need to understand the co-occurrence of narcissistic wounding and eating disorders, and methods for addressing this complex situation. Toward this end, we hope the article and case study in this issue of The Remuda Review will serve as a short primer on best practices for understanding, assessing, and treating this co-occurrence.
Narcissism and Eating Disorders
Volume 7, Issue 1
A. David Wall, PhD
Remuda Ranch Programs for Eating Disorders
“He heals the brokenhearted and binds up their wounds.” (Psalm 147:3)
Narcissistic wounds often contribute to the development and maintenance of eating disorders (EDs). This article defines narcissistic wounds, how they arise and affect behavior, how they relate to EDs, and how professionals can help individuals so wounded to heal.
Based on meta-analysis (Cassin & Ranson, 2005), narcissistic personality disorder (NPD) is diagnosed in somewhere between 2% and 16% of ED patients, with the lower estimate of 2% arising from the more reliable assessment procedures. Even among Remuda’s inpatients being treated at the intensive inpatient level, only 2% of adult patients are diagnosed with NPD traits. Nevertheless, on psychometrically reliable and valid measures of narcissistic beliefs, ED patients score significantly higher than non-clinical controls (Sines, Waller, Meyer, & Wigley, 2008). Research suggests that bulimic attitudes are associated with classic NPD traits (Brunton, Lacey, and Waller, 2005), and that restrictive eating is associated with the “poor me” form of narcissism in which others are viewed as abusive and the individual must, like a martyr, place others’ needs first (Brunton, Lacey, and Waller, 2005). As such, there is evidence that narcissistic wounding—a broader concept than NPD—is indeed related to ED development and maintenance. Below we explore the concept of narcissistic wounding in relation to EDs.
Freud derived the term, narcissism, from the classical myth of Narcissus and Echo. Narcissus was cursed to experience an unfulfillable love. As such, Narcissus fell in love, not so much with himself, but with his image. Stooping over a clear fountain, he saw his reflection in the water. He did not recognize the image as his own. He desired the person he saw, but each time he touched the image, the water stirred and the image disappeared, reappearing only as the water settled. Possessed by desire, Narcissus could not pull away, even when he discovered the image was his own. He would not leave the stream to eat, nor disturb his image to drink, so he died from hunger and thirst.
Echo saw Narcissus by the fountain and fell in love with him. But a goddess had punished Echo by taking away her voice, allowing her only to echo others’ voices, so Echo silently watched Narcissus’ plight. Brokenhearted by his death, she stopped eating until her body vanished. All that remained was her echo-bound voice, repeating others’ words.
This myth describes more than a self-centered young man and the woman who loved him. First, it astutely portrays the plight of those absorbed by self-image. ED patients can be as focused on their image as Narcissus. Sometimes their self-obsession appears vain, but most of the time they are obsessed with perceived flaws in their image, feeling disgusted and ashamed. These feelings may be hidden or openly expressed. In either case, the obsession with one’s image fails to deliver the love and validation which the person craves. The myth also portrays the plight of those obsessed with another. Like Echo, many ED patients have difficulty speaking their thoughts and feelings. They choose to sacrifice their own values and beliefs, indeed their own voice; to gain acceptance, they echo their peers, parents, or partner, hoping that this other person will fulfill their overwhelming needs for love and validation. But in the end their strategy does not work, as they lose their identities and never obtain the validation they had hoped for.
Narcissus and Echo may have been narcissistically wounded. Narcissus compensated through grandiosity and arrogance—classical narcissistic personality disorder (NPD). Echo’s compensation involved status by proxy. Echo believed that obtaining Narcissus’ love and acceptance, especially given how cruelly he was known to reject others, would provide her with status. She would be the only one good enough to win his heart. But, alas, it was not to be.
Development and Maintenance of Narcissistic Wounds
Kohut (Daniels, 2007) suggested that parents are mirrors from which children form their self-image. Most parents recall times their children performed for them, intently looking into the parents’ faces for a response. Children gain validation as parents reflect back acceptance, joy, and delight. Through this experience, children attach to their parents and grow beyond narcissistic approaches to the world. They develop healthy identities. Without healthy mirroring, children’s sense of self remains fragile, distorted, and self-focused.
Narcissistic wounds arise from repeated experiences of invalidation, such as rejection, neglect, conditional forms of love, and/or abuse. Central to narcissistic wounds is the spoken and/or unspoken message reflected back to the individual, “Who you are is not acceptable.”
When grooming in the morning, most of us look in the mirror. Once we adequately groom, the mirror tells us we look okay. So we stop grooming and move on with our day. However, if the mirror tells us we look unacceptable, we may feel compelled to fix what is undesirable. If the mirror continues to reflect back an objectionable image, we may hide our unacceptable feature(s) to avoid social rejection or embarrassment. We continue to work on our defects, trying to make them pleasing. The only way we can know if we have become satisfactory is to look in a mirror at our reflection.
In the same way narcissistically wounded people become obsessed with their image and try to get the mirrors—other people—to say they are okay. Some avoid mirrors—people—and rage at their own perceived ugliness and/or the failure of the mirrors to reflect back an acceptable image.
Developmental theorists recognize that children pass through a self-centered stage marked by grandiosity and omnipotent fantasies. Often extremely demanding, children in this stage have little frustration tolerance or ability to delay gratification. Freud termed this stage, primary narcissism, and believed it developmentally necessary and beneficial. The omnipotent fantasies gradually dissolve as children realize they do not have control and must depend on adults. In resolving the fantasies, children’s emotional attachment switches from self (narcissistic) to parents (anaclitic). But if resolution does not occur, children remain emotionally attached to themselves, grandiose and self-focused. Of course, resolution is not dichotomous, but a matter of degree.
Although traditional psychoanalytic theory posits that self-image forms early in childhood, modern research suggests that self-image may remain malleable into the early 20s, since the prefrontal cortex, involved in the development of self-image and understandings of how to react to others, develops slowly into the early 20s. During these years, specific environmental and relational circumstances are needed to guide brain development toward maturity. Karen Horney suggested that children “need to feel secure, to be loved, protected, and emotionally nourished...” to move out of primary narcissism (Vaknin, 2003). Frustration of these needs leads to narcissistic wounds and ongoing struggles to obtain love, safety, and value.
All people have inborn needs for love, acceptance, and security that include validation of their unique identities and age appropriate encouragement of autonomy. Environmental conditions that facilitate these needs provide children sufficient security to move beyond the narcissistic stage. If parents consistently reflect acceptance and joy, children learn, “I am acceptable and valuable. Even when I mess up, they still accept me, love me, and find joy in me. I can feel secure that I am loved and accepted.” If children learn that they are wanted and acceptable, they will not have to spend a lifetime trying to prove their worth and value. Once identity is firmly established and there is a foundation of security, it is safe to begin letting go of self-focus, learn empathy, and express genuine interest in others.
On the other hand, if children see disappointment or contingent acceptance in their parental mirrors, they believe they are disappointments and develop an ongoing struggle for acceptance. Kernberg (Frey, n.d.) viewed self-centered and grandiose narcissistic behaviors as defenses against cold and unempathetic parents. “Emotionally hungry and angry at the depriving parents, the child withdraws into a part of the self that the parents value, whether looks, intellectual ability, or some other skill or talent. This part of the self becomes hyperinflated and grandiose…, [and there is a] lifelong tendency to swing between extremes of grandiosity and feelings of emptiness and worthlessness.” Grandiosity becomes the compensatory strategy to deal with pervasive feelings of inadequacy, and focuses on what children perceived their parents to value. Accordingly, narcissistically wounded ED patients commonly come from families that value fitness and thinness and disdain people who are overweight.
If children do not experience validation, this narcissistic wounding obstructs and distorts the development of their identities, creating cavernous feelings of inadequacy and a constant need to seek out mirrors. The goal is to get the mirrors to reflect back a desirable image of self. Such individuals hope to see in others what they did not see in their parents: acceptance, joy, approval, a sense that they are special and important. When they see this image reflected back, they feel good. But sooner or later, the mirroring other will criticize or say “no” to the individual or focus on someone else. This perceived rejection becomes a narcissistic insult that opens up past narcissistic wounds, resulting in extreme pain and rage, known as narcissistic rage. Individuals then use compensatory strategies to deal with the pain and protect themselves from humiliation.
In this situation we see several components of the narcissistic process in action. Narcissistic wounding is exposed by a narcissistic insult, i.e., a response that replicates the original wound. Narcissistic rage follows, flowing out of the extreme pain of perceived rejection. Ultimately, compensation occurs to re-establish emotional equilibrium. With strong, ingrained compensatory strategies, individuals may move directly from insult to compensation; no one knows what occurred inside.
Psychoanalysis sees parents as the source of narcissistic wounding. Although sometimes true, we believe our culture, obsessed with accomplishments and status, separating winners from losers, also takes a huge toll on young people’s self-esteem. Peer culture can be horrendously cruel and is often the primary source of narcissistic wounds in ED patients. Below are examples of common narcissistic wounds.
How Families Narcissistically Wound Children
• Casting the child’s identity around a problem or disorder (e.g., “my problem child”) or, conversely, around one of the child’s gifts, talents, or attributes, as opposed to who the child is as a person.
• Attributing behavioral problems in childhood to permanent character issues.
• Routinely using shame, guilt, and/or fear to gain behavioral control of a child.
• Constant ridicule and/or sarcasm, especially in the absence of genuine affirmation.
• One parent allies with a child against the other parent, creating a dysfunctional family system that makes progression through the developmental stages difficult. The child is valued as a partner or ally, and not as a unique individual.
• A family system that does not tolerate change or individuality, and so fails to recognize and validate the child’s uniqueness.
• Isolating the child from the external world (e.g., peers, other viewpoints), thus preventing the child from discovering mirrors of his/her soul.
• Not filtering a child’s contact with the world via age appropriate restrictions, leaving the child to feel unprotected and thus undervalued.
• Inhibition and/or punishment of the separation/indivi-duation process. Children are not allowed to develop their identities and are punished by rejection or criticism when they do, forced to choose between parental acceptance and identity development.
• A parent spends very little time interacting with the child and seldom asks the child about her opinions and thoughts.
• Physically/emotionally-abused children develop the belief that they are objects for others’ wrath.
• An environment that creates constant competition between siblings and uses that competition as a means of control. In such an environment, approval is always conditional.
• An ADHD child is seen as bad by parents and/or school. This is especially wounding when siblings are well-behaved, high achievers.
• A child is placed in an inappropriate role, such as confidante, go-between, or counselor to her parents. This role shapes her relational template such that she cannot set boundaries and becomes the caretaker in future relationships. Although she hates this role, it also makes her special as she is trusted to handle adult problems.
• A female child is very close to her father. He suddenly reveals an affair and wants a divorce. She had absolute trust in her father and, in her view, this is direct abandonment/rejection of her. Her father chose another woman, knowing it would separate them. Regardless of his reassurances, the child is deeply wounded. Her feminine esteem is devastated: “Wasn’t I enough to keep him here?” The other woman is often younger and thinner than mom, teaching the child the importance of body image in maintaining relationships.
• Following a divorce, mom marries again and has a new child. The child from the previous marriage feels replaced by the new baby. There is hidden jealousy as the half-sibling is a full biological child in the new family, and has a father who loves her, an ideal family that is very different from the one the older child grew up in, and an ideal childhood whereas the older child’s was damaged. The sibling’s life rubs salt into the older child’s narcissistic wounds. The older child feels like an outsider, even a nanny. Her self-esteem is further injured by her own shame about her jealousy of the new child.
How Peers Narcissistically Wound Peers
Something’s wrong with you, so you don’t belong. A child has a deficit, e.g., speech impediment, physical anomaly, clumsiness, intellectual slowness, social naiveté, lack of social skills. Too often having problems like these is like bleeding in the midst of sharks: it precipitates a coordinated attack from peers. For example, as many as 80 percent of middle school students engage in bullying behaviors. Many students tease their peers to go along with the crowd (Kittredge & McCarthy, 2000). The victimized children often do not understand why others single out and make fun of them. They conclude they must be horribly defective. The wounding can be enormous, following these individuals through life.
No one is going to love you. A teen is ignored by the opposite sex. She is never asked out. If she shows interest in someone she is rejected, often cruelly. She may feel competent in other areas, such as academics, but in the key area of dating, she is a misfit. She concludes that no one will ever want her and she is doomed to be alone. She curses her face and body. She may try to compensate by becoming immersed in areas of perceived strength, such as academics.
You’re a loser, but you’ve got me! A peer latches onto an introverted child and makes her into her friend. Although the peer does enough to maintain the relationship, she seldom loses an opportunity to criticize or tease the shy child. The shy child learns to tolerate abuse as a condition of relationship. The cruel peer is dealing with her own sense of inadequacy through her one up status with her friend. The relationship keeps both children from being totally alone and makes them more acceptable to peers because they have a friend.
Join the club, pay the dues! Sexual activity is an expectation for inclusion in many teen social groups. “Girls from age 12 admit that pressure to have sex comes from all sides—boys, other girls, their friends and the media, [and] girls frequently cite incidents of boys as young as 12 or 13 calling [them] ‘bitches,’ ‘sluts,’ and ‘whores’ or making crude requests for sex” (Kittredge & McCarthy, 2000). Sexual pressure and promiscuity have narcissistically wounded many girls and women with EDs, as their identity becomes consumed within physical attractiveness. Guys may tell them, “I love you,” but this often means, “I love your body.” Girls lose sight of the difference between the two and feel valued only for their looks; the rest of who they are is devalued and unvalidated.
Relational Templates
Object Relations Theory posits a relational template—a mental guide for relationships based on early family relationship patterns that continues to shape and guide relationships throughout one’s life (Klee, 2007). Once formed, relational templates can be modified, “but our basic tendency is to seek out others, such as friends and spouses, who will reaffirm these early self-object relationships. It is as if in early childhood we create a script for a drama and then spend the rest of our lives seeking out others to play the parts” (Klee, 2007).
Seeking others to play the roles of key individuals from the past occurs by a process called projective identification. In mere projection, people attribute their own inner feelings, impulses, or experiences to other people. Projection is a passive process; we do not need others to act in a manner congruent with what we project onto them, we simply believe they are that way. Projective identification goes beyond mere projection, as it involves active manipulation of another person to behave like a key person from our past, in order to replicate and reaffirm early self-object relations. Narcissistically wounded individuals often engage in projective identification and replicate their early wounding with others. Such patients frequently use projective identification with treatment professionals as well, e.g., attempting to maneuver the provider so the provider behaves like the overprotective or rejecting parent who favors another sibling. Without awareness of this process, providers are vulnerable to the projective identification and may enter into relational patterns that do indeed replicate a significant relationship from the patient’s past.
It is important to understand that patients who use projective identification are not doing so malevolently or even consciously. They have simply learned to relate to others in this way. Some clinicians, when experiencing a patient’s efforts to replicate a past relationship, will say: “She is just doing it for attention.” It does not take a sophisticated professional to see that a patient craves attention. However, it does take experience and skill to know why patients are craving attention, to understand their relational templates, and to help them move beyond their unhealthy ways of receiving attention toward healthier methods that can potentially heal their narcissistic wounds.
From Narcissistic Wounding to Personality
Narcissistic wounds may result in the personality characteristics of DSM-IV’s NPD—arrogance, lack of empathy, focus on power, and entitlement. Our clinical experience with thousands of ED patients suggests that narcissistic wounds may also result in other personality characteristics, some quite different from NPD. The range of personality characteristics arising from narcissistic wounds varies according to each child’s temperament, environmental conditions, and inherent and developed attributes, such as intellect, athleticism, and physical appearance. Common personality characteristics of narcissistically wounded individuals include:
• Strong feelings of insecurity and inadequacy.
• Fragile ego, being easily hurt and prone to become defensive.
• Constant comparison of self with others.
• Self-conscious and hypersensitive to the reactions of others.
• Egocentric and self-focused, but not necessarily egotistical as in classic NPD.
• Conflicts between dependency and autonomy, caused by insecurity and affirmation needs conflicting with distrust and fears of being hurt.
• Extreme sensitivity to rejection, anticipating rejection or betrayal.
• Difficulty accepting compliments, as they are likely to be conditional.
• Sense of self-worth easily swayed by current circumstances and emotions.
• Inner pain and rage, where rage may be turned toward others or oneself.
• Chronic feelings of humiliation.
The methods that individuals develop to compensate for their narcissistic wounds vary and are by no means restricted to NPD behaviors. Narcissistic compensation is an effort to get other people to mirror back an acceptable image. As Vaknin (n.d.) writes:
We all search for positive cues from people around us… There is nothing special in the fact that the narcissist does the same… The normal person is likely to consume a moderate amount of social approval … in the form of affirmation, attention, or admiration. The narcissist … asks for more and yet more…
Vaknin (2003) continues by noting that narcissistic individuals project fictitious versions of themselves, known as false selves. For those with classic NPD, the false self is omniscient, omnipotent, charming, intelligent, rich, or well-connected. The purpose of the false self is to gain the validation the individual craves. For narcissistically wounded individuals, the false self may not always be grandiose, but can take a variety of forms. Any false self that garners the needed attention will do.
Most ED patients are painfully aware of their false selves. On countless occasions I have listened to patients talk about their masks. They wear masks because they have a core belief that the person they are inside is unacceptable and must be covered up. This belief is not innate; somewhere along the way they experienced extremely painful events that burned this message into them.
Operating within a cognitive-behavioral therapy (CBT) framework, Beck described methods of compensating for perceived inadequacies as compensatory strategies (Beck, Freeman, Davis, & Associates, 2003). Compensatory strategies protect individuals from further relational pain, partially meet their needs for acceptance, identity, and worth, and shield individuals from their inner pain, emptiness, shame, and aloneness. Compensatory strategies begin in childhood and continue throughout individuals’ lives. Although these patterns can change, especially during crisis, they usually become ingrained. For some, compensatory strategies are so deeply ingrained that the individuals no longer experience their insecurity. Nevertheless, it continues to drive their actions.
The following examples demonstrate common false selves—the compensatory strategies of the narcissistically wounded.
• Seeking to be the best, e.g., in academics, sports, business, evangelism.
• Seeking to be the most beautiful, sexually desired, or thinnest.
• Seeking an ideal romance or the perfect relationship in the belief that this relationship will finally meet the unmet needs for acceptance and validation.
• Reverse or closet narcissism: “If I am not the best, then I will be the worst.” The individual does not present a grandiose, inflated false self, but a deflated, inadequate self (Masterson, 1981); e.g., being the sickest or the one with the most trauma. This leads others to caretake, reassure, build up, pay attention, and validate the individual’s heroism.
• Seeking to be needed and indispensable through caretaking others.
• Convincing others that they need the individual.
• Constantly drawing attention back to oneself. E.g., when someone tells a story, the person often responds, “That’s nothing, I…”
• Being dependent, eliciting nurturance missed early in life.
• Constantly putting others down, gossip, backbiting. In contrast, one’s identity appears acceptable and/or elevated.
• Arrogance and superiority.
• Façade of adequacy and independence.
• Exerting power over others by physical force, position, or emotional manipulation/intimidation/control, to force others’ respect and prevent others from further wounding the individual.
• Seeking fame or high status.
• Vicarious Narcissism: living through another person or group of persons, often one’s children or high status figures/celebrities. The individual gains validation by identification with the other person’s accomplishments. We discuss vicarious narcissism in more detail below.
Vicarious narcissism occurs when individuals gratify their narcissistic needs through other people. Personal boundaries blur as individuals react to another person’s experience as if those experiences were their own.
Vicarious Narcissism can occur in fans’ identification with athletic teams. Some fans over-identify with athletic teams, as if they were members of the team. When the team wins it is a personal victory for the fan; when they lose it is a personal loss. The language used demonstrates the blurring of identity, “we’re gonna kill ‘em”. In many cases this is benign. In the extreme, some narcissistically wounded fans take this to the point of violence, when the team lets them down or they believe an official caused the loss of a game.
Celebrity stalkers gratify unmet narcissistic needs through fantasy-based relationships with the celebrity. The celebrity’s high status combines with the fantasized connection; the stalker feels important and special. Sadly, this too can end in violence, especially when the stalker tries to make contact with the celebrity and is rejected or ignored—a narcissistic insult leading to narcissistic rage.
When rejected or betrayed, some lovers and would-be lovers demonstrate narcissistic rage by violent attacks, including murder. Police often know that the murderer had a romantic connection with the victim because of the extreme nature of the attack, going well beyond what was necessary to kill the individual.
In some parent-child relationships, the child is used as an object through which parents meet their narcissistic needs for attention and affirmation. Rappoport (in press) refers to the child in this scenario as a co-narcissist who must accommodate narcissistic parents. “Co-narcissistic people, as a result of their attempts to get along with their narcissistic parents, work hard to please others, defer to other people’s opinions, worry about how others think and feel about them, are often anxious and depressed….” Narcissus loved his own image. Accordingly, if you want a narcissistic person to love or accept you, you need to look and act like that person. If you want a narcissistic parent to love and accept you, you need to be exactly like that parent. Narcissistic parents “...see the children as extensions of themselves, and need the children to represent them in the world in ways that meet the parent’s emotional needs…. The children are punished if they do not respond adequately… including physical abuse, angry outbursts, blame, attempts to instill guilt, emotional withdrawal, and criticism.” Because we are ultimately incapable of meeting another person’s narcissistic needs, these children fail. They thus develop narcissistic wounds in two ways: not being allowed to develop their own identities and failing at their primary role in the family.
Narcissistic Wounding and Body Image
Individuals in our culture, especially women, are often judged by physical appearance more than other attributes. In essence, females are taught, “You are your body.” Objectification Theory asserts that sexual objectification is the treatment of a woman’s body as an object for the pleasure and use of others (Slater & Tiggeman, 2002). Sexual objectification is so pervasive and its influence so strong that it causes females to internalize this objectification of their bodies. Girls and women “adopt an observer's perspective… [and] treat themselves as an object to be looked at and evaluated on the basis of appearance.” This internalization, called self-objectification, is “…characterized by habitual and constant self-monitoring of one’s outward appearance.” Self-objectification leads not only to body monitoring, but also to appearance anxiety and body shame. In Remuda’s extensive experience, body shame clearly plays a direct causal role in the development and maintenance of EDs.
In light of these cultural pressures, one can see that ED individuals’ perceptions about the importance of physical appearance cannot simply be dismissed as irrational thinking. Indeed, studies have found evidence of positive bias toward those deemed attractive. A meta-analysis found that people who are perceived attractive are judged more favorably in a variety of areas and treated more positively, including in employment decisions (Langlois, et al., 2000; Marlow, Schneider, Nelson, 1996).
Objectification Theory adds to our understanding of body image issues in ED patients suffering from narcissistic wounds. A woman experiences her body as an object. She is aware that her body can bring her acceptance in high status groups, the interest of high status males, prestige, preferential treatment, attention, affirmation, and more. She becomes vulnerable to the cultural messages about appearance and internalizes the culture’s perspective, including the extreme importance it places on appearance. Since she already experiences her body as an object, in the manner of vicarious narcissism, she views her body as the vehicle to meet her narcissistic needs for acceptance, identity, and worth.
In vicarious narcissism, when the object fails to supply validation, the individual rages at the object. Likewise, when she feels unacceptable or is rejected, she rages at her body. She calls herself a “fat pig,” punishes her body, and tries to whip it into shape. She restricts how many calories her body may consume and eliminates pleasurable food items. She engages in nonstop compulsive exercise where each calorie consumed is matched by calories burned in exercise. She self-mutilates. But ultimately her body cannot meet her needs to be accepted, loved, and seen as special. First, it will let her down, because bodies are imperfect. Second, whatever acceptance she manages to gain through her appearance is conditional, and does not truly validate who she is inside. Her narcissistic wound remains. But because physical appearance is so highly valued in our culture, she will continue to blame her unhappiness on her body and believe that she will be happy if she could “just lose 15 pounds…”
Extremely attractive girls and women are highly reinforced for their appearance. They must constantly monitor and protect their beauty because they often do not know their value without it. The ED is a way of insuring that they will not become fat, which would equate to losing the much needed reinforcement that soothes the narcissistic wound.
Others, less sure of their appearance, succumb to the incredible value that our culture places on appearance and are driven to prove to themselves that they are attractive. They dress provocatively and become promiscuous. Subsequent male attention gives these women evidence that they are attractive. However, sexual experiences cannot fill the void within. Rather than increase self-esteem, promiscuity often leads to shame. Such women may self-harm, binge eat to numb their emotional pain, then purge out of fear of getting fat and losing the affirmation they gain through their appearance. Some women are trapped in this process, as their need to prove their worth remains unquenched.
For some, their appearance itself has been a narcissistic wound. They were teased by peers for their appearance, ostracized, and tortured through tricks and taunting. Sadly, childhood obesity can elicit such peer cruelty. ED patients with histories of childhood overweight have what I call, the trauma of obesity. These children were truly traumatized. Post traumatic stress disorder includes efforts to avoid activities, places, or people that arouse recollections of the trauma. For these individuals, their own body, as an object, is the source of trauma. In their view, the ED prevents their body from losing control, gaining weight, and returning them to the trauma.
Treatment Issues
Whether a narcissistic wound manifests in classic NPD symptoms or otherwise, the wound can make therapy difficult. Through projective identification the patient will actively attempt to get the provider to take on a specific role to replicate past conflicts. The patient can be highly frustrating, expecting and perceiving rejection from the therapist. Without recognizing this, providers can play into the projective identification, becoming impatient and critical, and reporting to colleagues, “this patient doesn’t want to get better and isn’t motivated.” Patients with an ingratiating compensatory style can have the opposite effect. Providers feel sorry for them, may believe other staff are being unfair to these patients, and may allow patient dependency without recognizing it.
Essentials of Treatment
Treatment involves several key ingredients that can be offered from CBT or psychoanalytic perspectives.
Assess Issues. Find out if there have been significant narcissistic wounds by taking a good history. Patients’ emotional functioning is based on their perceptions, regardless of how accurate they are. The goal is not to blame parents or take sides, but to understand how patients see themselves and the world. The basic components of narcissistic wounding in this article will help in this assessment. It is also important to learn how patients compensate for their wounds, and the role the ED plays in this compensation.
Validate Wounds. Start with the wounds. Help patients talk about them. Not talking about their wounds is an obstacle in treatment. Patients must express their wounds, but if they will not move beyond their wounds and choose to hold onto them, they will not heal. Providers need to validate the wounds. Validation means recognizing that someone hurt the patient badly, whether or not this took place exactly as the patient reports. People do not have severe emotional problems simply because they want to have such problems. Even if patients are seeking attention, emotionally healthy people do not go to extremes to get attention, so it is essential to recognize and validate that something truly painful has happened to our patients. Patients need to understand that they were hurt badly and that their problem behaviors are their best attempts to deal with their pain. This greatly reduces patients’ shame, without reducing their responsibility to do something about their situation.
Teach Relational Templates. Both Object Relations and CBT recognize that individuals create templates/schemas that guide how they interpret events in their lives. It is important to understand these templates. Once assessed, begin by helping patients to recognize their patterns. Help patients understand their patterns and compensatory strategies as attempts to handle problems in the best ways they have known, while communicating that they can develop new ways.
Teach New Skills. Recognizing patterns and gaining insight without the tools to make changes does not lead to sufficient change. CBT skills are critical. Patients need to recognize how their past learning impacts how they interpret events and how to challenge these interpretations. The most critical aspect of this is not changing irrational thinking, but providing patients with cognitive, behavioral, and emotional skills that allow them to form healthy relationships, being cognizant of old patterns and inserting new skills to take their place.
Address Spiritual Issues. Narcissistically wounded people have distorted identities built on superficial and fragile foundations. They must learn that they are special, unique, and acceptable, even though their compensatory behaviors may push people away. Their need for compensation is built upon a false premise–that they are unimportant. As they learn exactly how important they are, their need to compensate can dissipate in time. Learning about their value can be enhanced through spiritual considerations. We address spiritual considerations in more detail below.
Spiritual Considerations
Some Christians are suspect of positions that affirm the importance of self-esteem and self-worth. They point to Scriptures such as Jesus’ call to deny ourselves and take up our cross (Matthew 16:24). This is an understandable reaction to concerns that our culture has grown hedonistic and selfish, the “Me Generation”.
God is uninterested in feeding self-centered desires for fame, supremacy, or admiration, or in rewarding arrogance. The desire to be worshiped was the very sin that caused Lucifer’s fall (Isaiah 14:11-23). The desire to be like God was also key to Adam’s and Eve’s disobedience. Christians are not called to be lovers of self (2 Timothy 3:2). The Greek word for love in this verse refers specifically to a self-indulgent love bent on one’s own pleasure and gain.
Scripture makes clear that the opposite of hedonistic love is equally wrong. “Let no one keep defrauding you of your prize by delighting in self-abasement…” (Colossians 2:18, NAS). “Don’t let anyone condemn you by insisting on self-denial” (Colossians 2:18, NLT). Self-abasement is a sense of moral littleness, shame, and low self-esteem. Scripture tells us that God does not want this for us. In fact, self-abasement is a form of false humility. Those who engage in self-abasement often feel self-righteous inside: they are proud of their self-denial.
Rather, we are called to true humility. True humility understands that our worth is not based on any of our attributes, but on the fact that we were intentionally created in God’s own image. In Matthew 19:19, Jesus commands us: “You shall love your neighbor as yourself.” The word used for love is agape, a charitable and giving type of love involving action. We are commanded to love our neighbor as ourselves, because it is understood that we already love ourselves. And the fact that we already love ourselves in the manner of agape is assumed to be good—so good, that we are commanded to extend this love to others.
As such, humility does not flow out of low self-esteem or a lack of self-worth. Humility, in its greatest expression, was evidenced by God choosing to become a man, serving others in agape love, ultimately dying for them. Although powerful, Jesus chose to be humble out of love. As such, humility involves choice and power, the choice and power to love others. As the Bible tells us in Philippians 2, we should “…with humility of mind regard one another as more important than yourselves…” The Bible does not say that we are less important than others, but tells us to regard others as more important as an act of agape love.
People narcissistically wounded in childhood have either a very weak or false sense of control. They have a false power or feel that they lack power altogether. Narcissistically wounded people do not have the power to be humble; they are either arrogant or have such incredibly low self-esteem that they constantly hide behind a facade. In the Greek New Testament, humble means “to lower to the ground”. How can someone who is already extraordinarily low in their own perception choose to lower themselves any further? They cannot.
People with wounded self-worth focus on themselves, much like someone with a migraine headache has a hard time focusing on anything but the headache. Only when we feel valued and significant are we capable of thinking about others above ourselves. C.S. Lewis (2001) wrote, “…if you meet a really humble man he will … not be a sort of greasy, smarmy person, who is always telling you that … he is nobody. Probably all you will think about him is that he seemed a cheerful, intelligent chap who took a real interest in what you said to him. If you do dislike him it will be because you feel a little envious of anyone who seems to enjoy life so easily. He will not be thinking about humility: he will not be thinking about himself at all.”
Children go through a narcissistic, self-focused stage. So how does a child move out of that narcissistic stage? The parent loves and lifts up the child; the child then learns how to return this love. Christians go through an analogous realization of our sinfulness and lack of worth. How does God deal with our lowly position and shame? He loves us and lifts us up; then, in response, we love him. “We love because He first loved us…” (1 John 4:19). Without the love of God we would remain self-absorbed. His love and building us up set us free and give us the choice to be humble. The same type of love, reassurance, and validation that God gives us are exactly what children need to form strong egos that can choose to value others and put others’ needs above their own.
God recognizes and values our desire to be significant. For example, Jesus’ disciples came to him asking which of them is greatest (Luke 9). Jesus did not tell them that their desire to be great and significant was wrong. Rather, He told them that their method was wrong. He affirmed that it is right to want significance, but that we do not become significant by lording our will over others. We become significant by choosing to serve and care about others in love.
Our culture has departed from valuing what leads to self-esteem. We admire and envy the rich and powerful, we worship the beautiful and talented, we call students with good grades “honor students,” when, in some cases, their moral character may demonstrate anything but honor. We live in a society where status derives from winning at competitions, whereas God wants us to cooperate and help each other succeed. Our schools teach survival of the fittest to explain how human beings evolved. Children are taught that living creatures compete for limited resources and that the winner gets to live and reproduce, implying that nature favors the strong, the fast, and the intelligent, and rewards those who possess these traits with survival. Life is just one big competition. Athletes have multi-million dollar contracts; teachers are poorly paid. Our culture suffers from the curse of “est”—the need to be the strongest, smartest, fastest, prettiest, thinnest, “baddest”, richest, and toughest. So self-esteem is based upon being the best, but the only way for one person to be the best is for others to lose.
Narcissistically wounded individuals lack self-esteem and value, so they constantly try to obtain value and worth. To do so, according to our culture, they must win and be better than others: this will make them special. As such, countless girls are competing with their peers to be the thinnest.
God created all of us with a legitimate desire to be special. This means that we are irreplaceable, but not better than anyone else. Jesus talks about going after one lost sheep and leaving the other 99 to do so (Luke 15). The message is clear: everyone is irreplaceable. Without this core Biblical understanding of our value, we fill the void with lovers, money, power, EDs, substances, and so on. Yet the Bible wisely counsels: “Why spend money on what is not bread and your labor on what does not satisfy? … [E]at what is good, and your soul will delight in the richest of fare” (Isaiah 55:2).
With this Biblical understanding of self-esteem, Christian therapy proceeds as follows. It builds trust to touch the wounded place, so that patients can receive affirmation of their importance as persons uniquely desired and created by God—not as bodies, grade point averages, or athletes, but as souls. Wounded persons must discover that it is safe to admit their dependence on God and receive their value from a healthy relationship with God and others. Wounded people are educated about how they have sought apart from God to meet their God-given needs for identity, worth, love, acceptance, security, and significance. These goals are important and valid, but their compensatory methods are ineffective and will never heal their inner emptiness. Wounded patients are assisted in developing new and effective ways to meet their needs. Yes, they need support and validation from other people, but they do not need to become dependent on anyone. Just like children need positive mirroring, wounded patients need others to reflect back to them the worth that God has given them. And they need to look directly into the heart of God, who radiates his pleasure, love, and acceptance of them through the redeeming grace of Jesus Christ. “For God so loved the world, that He gave his one and only Son, that whoever believes in him shall not perish but have eternal life” (John 3:16). “And I pray that you, being rooted and established in love, may have power, together with all the saints, to grasp how wide and long and high and deep is the love of Christ, and to know this love that surpasses knowledge—that you may be filled to the measure of all the fullness of God” (Ephesians 3:17-19).
References
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Case Study: Narcissism and Bulimia Nervosa
Volume 7, Issue 1
Sherrie L. Maher, PhD
Remuda Ranch Programs for Eating Disorders
Julie, age 19, came to Remuda following an intervention. She was well dressed, consistent with the latest in fashion. Her father was a respected surgeon, her mother a homemaker raising Julie and her older sister. Julie’s parents had reached their limit with her bulimia, and had locked the refrigerator to stop Julie from binge eating.
Julie’s mother had once been in beauty pageants. At Julie’s age she had represented her home state in a nationally televised pageant, placing 3rd. Julie was born with her mother’s stunning physical appearance and was expected to follow in her footsteps. As such, Julie was enrolled in beauty pageants starting at age three.
Julie recalled that her mother would work with her for hours, teaching her to walk with grace, practicing poses, and developing her singing. Julie’s singing scored many points at pageants. But when she did not meet her mother’s singing standards, her mother would scream at her and accuse of her intentionally trying to sabotage her mother’s hard work. Julie’s mother often told Julie about how hard she had worked at pageantry and how she would have been successful and famous if she had not become pregnant at age 21. Now it was Julie’s chance to make something special of herself. She needed to try harder. As part of Julie’s training, her food and exercise were carefully monitored.
Julie’s sister, Andrea, was their father’s favorite. Her sister took after their father in temperament and was thinking about medical school. Julie secretly yearned for her father to love her as well, but she could never talk to anyone about that. Besides, she told herself, she had more friends than Andrea.
During collateral interviews, Julie’s father revealed that Julie had always exhibited a great deal of rage. This was especially true when things did not go her way or she was criticized. About two months ago, Julie had ripped an expensive pageant dress to shreds because she could not get the zipper to work. Julie was also hostile and cruel to her sister.
Andrea revealed that she goes out of her way to avoid making Julie angry, so as not to trigger Julie’s screaming fits. Andrea indicated that Julie often takes things the wrong way and as criticism. In retaliation, Julie points out her sister’s flaws, often making extremely cruel comments about Andrea’s appearance. Julie admitted that she often screams at her sister and that she is extremely critical of her. This had created a distance between them.
Julie saw herself as popular and having tons of friends, however she did not seem to have any deep friendships. She was the life of the party and knew she was extremely attractive to men of all ages. She saw herself as a femme fatale and a “man eater.” Julie believed that when she was thinner she was “even more of a threat to men” and therefore could have any man she wanted. She had an extensive sexual history and talked about it as an accomplishment. Although her mother never openly approved of how much Julie dated, her mother often boasted to family and friends about how, “the boys just won’t leave Julie alone. I just don’t know what I am going to do.”
Julie clearly evidenced criteria of narcissistic personality disorder. I learned that her bulimic behaviors were entwined with her narcissistic issues. She would binge eat, at least in part, to get even with her family, especially her mother, because their fear for her well-being and concern that she might get fat were easily manipulated. She purged, fasted, and restricted calories, because of how important her appearance was to her in obtaining attention and affirmation from others.
Julie’s psychological testing indicated that she would have a difficult time developing insight into her own motives and behaviors, as well as those of others. She would likely have somatic problems to procure attention or avoid responsibil-ity. Julie reported that, when sick, she received more attention from her father. In fact, her father had been much more attentive to her since she was diagnosed with bulimia.
At Remuda, Julie was very demanding with staff. She raged, sometimes at drop of a hat. She took on a condescending and superior attitude with staff and all but a few select peers. In classes, Julie always volunteered and emerged as the leader of discussions. During meal times, Julie hid food on her body and resorted to other means to avoid eating. Once discovered, staff began to check her after meals. Rather than accepting responsibility for her behaviors, Julie often blew up at staff, talking about how unfairly they treated her, even when it was obvious to everyone, including herself, that she had indeed hid her food.
In therapy, it became clear that Julie had a very fragile ego, despite her outer appearance of confidence and power. She was like a house built on the sand, without a foundation to hold her. Julie had to be approached very carefully in therapy. Although it was important from the start to help her understand the guidelines for behavior in the milieu, confronting her attitudes and behaviors in therapy sessions resulted in power struggles such that entire sessions were spent arguing about whether or not the rules were fair or why they had been applied to her.
Clearly, before she could be challenged on her behaviors and the need to take responsibility for her actions, she first had to become aware of her needs and wounds and have these needs and wounds validated. Her wounds included feeling that her father loved her sister more and that her father was proud of her sister, highly valuing her sister’s academic success and “what a mature young lady she is becoming.” Julie knew her father loved her, but never felt that he was proud of her or who she was becoming as a person. Her wounds also included her sense that she had to be a clone of her mother if she wanted her mother’s love, attention, and respect. She had to become what her mother wanted her to become, value what her mother valued, and never deviate from her mother’s plan for her life. If her opinion differed from her mother’s or she did not share her mother’s passion about something, her mother screamed at her, or worse, stopped talking to and working with her. In these cases, she was made to feel guilty for having her own opinion. Her mother would say, “Fine if you want to throw away all that we have accomplished. I have sacrificed so much for you, and you don’t even care.” Julie’s guilt would lead her to apologize. In short, it was not okay for Julie simply to become who she was created to be.
Much time was spent in therapy addressing the crucial issue of naming, explaining, and validating Julie’s wounds. The danger at this stage of therapy was that Julie might blame her mother and simply redirect her anger. Therefore, Julie had to learn that, at this point in her life, she needed to be responsible for choices. She did not need blame herself or beat herself up emotionally, but to learn new ways to regulate her emotions, to meet her needs based on what is truly healthy for her, and to communicate, especially with her family. These themes and the impartation of skills were woven consistently into Julie’s individual and group sessions, as well as her experientials.
Spiritually, Julie needed to learn that God is loving and accepting. Julie was a Christian, but did not experience God’s love or favor. Her faith deepened through attending daily chapels at Remuda and near the end of treatment she began practicing the presence of God, to experience his comfort and love in a palpable way. She appeared to be opening to this. Indeed, she was finding a new path for herself. She realized that her sexual promiscuity only helped her to feel better temporarily, which is why she went from guy to guy. Her growing faith and experience of God’s grace were enabling her to realize that what she wants from a man is not just physical love and validation, but love for who she is as an individual. Her awakening faith also helped her to release deep feelings of shame arising from years of her mother’s criticism and her own cruel behaviors toward her sister and other people.
Halfway through treatment, Julie seemed to be developing some empathy for others, but still has work to do in this regard. She was treating other patients with greater respect and felt more accepted by the group as a whole.
With much preparation through family teleconferences, Julie’s truth in love sessions during Family Week were successful. Julie reached some insight into her mother’s past experiences and the pain her mother carries, and her mother was able to see how she was trying to make up for her own insecurities through Julie. Issues with Julie’s father were only lightly addressed. The family clearly needed substantial additional family work; this became part of the aftercare plan. In addition, it was recommended that Julie’s mother pursue individual therapy, as she began to recognize her own wounds, including feelings that she was not getting the attention from her husband that had once been there.
It would be nice to say that by discharge she was beyond raging, but she was still losing control of her anger at times. She completed several behavior chain analyses, which taught her to look at internal and external events leading up to a rage episode, as well as her thoughts and interpretations of situations. These exercises helped her to recognize potential rage episodes early in the process when they are easier to control and decreased the frequency of her rage episodes. Another change was that, after having a rage episode, she was able to recognize why she raged in that situation, and thereby discover what she could do to change the outcome next time. At discharge, we were optimistic that over time she would continue to understand her internal attributions well enough to avoid most episodes of rage.
Introduction to Body Dysmorphic Disorder and Eating Disorders, Volume 6, Issue 3
With the current issue of The Remuda Review, we continue our series of articles on common co-occurring problems faced by eating disorder patients. Throughout this series, we are considering the assessment, conceptualization, and treatment of self-injurious behavior, anxiety disorders, mood disorders, substance use, trauma, personality disorders, and other co-occurring issues within Remuda’s bio-psycho-social-spiritual model. In each article, we consider how these co-occurring issues relate to eating disorder development, symptoms, and maintenance, and, where relevant, variable manifestations based on age, development, and culture.
The present issue focuses in depth on our eighth topic: body dysmorphic disorder (BDD) and eating disorders. A surprisingly large percentage, 39%, of patients with eating disorders have BDD. Yet BDD is rarely diagnosed in those with eating disorders, due to diagnostic and symptomatic overlap, as well as lack of clinician awareness. Comorbid BDD intensifies patient distress and suicidality, and complicates treatment. As such, there is a clear need to understand the co-occurrence of BDD and eating disorders, and the best, evidence-based methods for addressing this dual diagnosis. Toward this end, we hope the article and case study in this issue of The Remuda Review will serve as a short primer on best practices for understanding, assessing, and treating this co-occurrence.
Body Dysmorphic Disorder and Eating Disorders
Volume 6, Issue 3
Eileen Adams, MS, LMSW
Marian C. Eberly, RN, MSW, LCSW, DAPA
Kevin Wandler, MD
Yong Lee, MD
Remuda Ranch Programs for Eating Disorders
[F]ix your attention on God. You'll be changed from the inside out… Unlike the culture around you, always dragging you down to its level…, God brings the best out of you... (Romans 12:2, The Message)
Although it may seem that body dysmorphic disorder (BDD) exists primarily in modern Western societies, it has been documented since the 1800s worldwide. In 1987, BDD entered the DSM as a somatoform disorder.
BDD can co-occur with eating disorders (ED). When it does, it can be difficult to detect since presenting symptoms overlap with EDs as well as with ED’s common comorbidities of obsessive compulsive disorder (OCD), social phobia, and major depression (Arthur & Monnell, 2005; Phillips, 2005). As such, for correct diagnosis and treatment ED professionals will benefit from understanding the differentiating features of BDD.
Powerful cognitive distortions regarding one’s appearance are a key feature of BDD. BDD patients are preoccupied with imagined or slight defects in their appearance—defects that are minimal or undetectable to others. BDD patients thus struggle with others’ lack of reaction to their perceived defects. Patients’ time consuming and profound obsessions with their perceived defects are intrusive, unwanted, ego-dystonic, potentially disabling, and of near delusional intensity. Yet patients consider their perceptions to be completely rational. The term overvalued ideation describes the high value patients place on their beliefs, arising from their strong feelings about their perceived defects—feelings that eclipse rational cognitive insight (Neziroglu, Roberts, & Yaryura-Tobias, 2004).
Compulsive reassurance behaviors such as frequent appearance checks in mirrors or reflective surfaces typify some, whereas other sufferers eschew their image at all costs, covering mirrors and going out of their way to avoid their reflection. Patients can spend excessive time and money on grooming rituals, special lighting, and magnifying mirrors. They commonly wear clothing that covers perceived imperfections or camouflages the body. Such camouflaging usually offers little relief, so patients often end up isolating themselves or becoming housebound. This can impact major areas of psychosocial functioning (Neziroglu et al., 2004). Some even quit school or lose jobs.
BDD often begins in adolescence. Sub-clinical BDD can start as young as age 12 (Neziroglu et al., 2004). Onset can be gradual or abrupt. Because of normal developmental increases in appearance concerns during adolescence, clinicians must gain skills to discern the excessive preoccupations characteristic of BDD. Importantly, BDD symptoms interfere with normal adolescent development, such as self-esteem and peer relations (Phillips, Didie, Menard, Pagano, Fay, & Weisberg, 2006).
BDD patients feel much shame about their perceived defects and associated behaviors. Secrecy is therefore common, complicating clinicians’ ability to recognize and diagnose BDD (Neziroglu et al., 2004). While symptom-free periods are rare, symptom intensity may ebb and flow. When one imagined defect is resolved, focus may change or switch to another body part. With fluctuations in symptom intensity and focal body part, BDD often goes undiagnosed for years.
BDD can lead to suicide. Suicidal ideation and attempts in BDD adolescents may be five times greater than in US adolescents in general; half the adults with BDD may have suicidal ideation and 12% make suicide gestures (Phillips et al., 2006). Up to 29% of BDD patients actually attempt suicide, with suicide risk highest in BDD women with perceived facial defects (Arthur & Monnell, 2005). Because BDD patients are at high risk for suicide, BDD evaluations always include thorough suicide assessments.
BDD is evenly distributed among males and females (Phillips, McElroy, Hudson, & Pope, 1995). In community samples, BDD prevalence ranges from 0.7% to 1.1%, with highest prevalence, 2%-13%, in non-clinical student samples. BDD occurs in 13% of psychiatric inpatients (Phillips, Menard, Fay, & Weisberg, 2005). Typically, BDD patients are unmarried, have few friends, and suffer personally, professionally, and educationally as the disorder takes over their lives (Arthur & Monnell, 2005).
Many BDD patients seek dermatological and surgical interventions. More than 12% of BDD patients are diagnosed in dermatology settings (Phillips et al., 2005). Nearly 15% of cosmetic surgery patients have BDD (Phillips et al., 2005). When multiple surgeries result in disfigurement, patients’ obsessions usually worsen.
BDD etiology is unknown. Heredity may play a role as lifetime BDD occurs four to eight times more often in BDD families. Perceptual and emotional information processing research suggests abnormalities in executive functioning, emotion recognition, and visual self-perception. Serotonin may play a role in modulating BDD behaviors (Saxena & Feusner, 2006).
Many BDD sufferers report being positively reinforced for their appearance throughout childhood. Others recall public humiliation. Significant traumatic events such as sexual assault, sexual harassment, public failure in athletics or dance, physical injury or illness, and teasing about appearance may trigger negative thoughts and shame regarding appearance and self-worth (Cororve & Gleaves, 2001). Family and personal experiences that result in feeling unloved, insecure, and rejected are also BDD risk factors. Influences from media and culture strengthen beliefs that worth and acceptability come primarily from physical beauty.
Recent research suggests that 79% of BDD patients have histories of childhood abuse and neglect (Didie, Tortolani, Pope, Menarda, Fay, & Phillips, 2006): 68% emotional neglect, 56% emotional abuse, 35% physical abuse, 33% physical neglect, and 28% sexual abuse. Abuse severity was high. History of sexual abuse also increases BDD severity.
BDD has similar psychiatric comorbidities to ED. Depression occurs frequently with both disorders and considerably more so than in the general population (Phillips, 2005; Kessler, Wai, Demler, & Walters, 2005; Wall, Eberly, & Wandler, 2007). Phillips et al. (2005) report that 75% of BDD patients in their study have comorbid depression. For ED patients, the figure can run as high as 98% (Wall & Cumella, 2006).
The obsessive and sometimes compulsive nature of BDD intuitively groups this disorder with OCD. The similarities are so numerous that experts are debating its classification as an obsessive-compulsive spectrum disorder (Phillips et al., 1995; Hollander, 2006). Up to 39% of BDD sufferers have comorbid OCD (Phillips et al., 2005). OCD and obsessional personality characteristics also occur in 11% to 69% of women with anorexia (Pearlstein, 2002). For both BDD and ED, then, lifetime prevalence of OCD is much higher than the 1.6% found in the general population (Kessler et al, 2005).
In one study, 40% of BDD patients met criteria for social phobia (Phillips et al., 2005). In ED patients, comorbid social phobia is also common, at 50% to 55% (Pearlstein, 2002). Similar clinical features exist between BDD and social phobia, such as social avoidance, feeling embarrassed and defective, and fearing public ridicule (Coles, et al., 2006). Due to the high comorbidity and clinical similarities, experts suggest routine BDD screening for patients with social phobia (Veale, et al, 1996, as cited in Coles, et al., 2006).
Diagnostic Issues
Both BDD and EDs include body image distortion and dissatisfaction as core symptoms. BDD diagnostic criteria instruct clinicians to diagnose an ED if body concerns are limited to “fatness” (American Psychiatric Association, 2000). However, some individuals have both concerns about their weight and shape—meeting ED criteria—and additional appearance concerns such that they indeed have co-occurring BDD. Studies suggest that there may be many more individuals with both disorders than once thought. Of patients with EDs, as much as 39% may have co-occurring BDD (Grant, Won Kim, & Eckert, 2002). In one study, 81% of teens with anorexia reported that BDD, not ED, was their “biggest or major problem” (Ruffolo et al., 2006). For 63%, BDD preceded ED onset. Of those with BDD, 33% may have comorbid lifetime ED—9% anorexia nervosa, 6.5% bulimia nervosa, and 17.5% ED not otherwise specified (Ruffolo, Phillips, Menard, Fay, & Weisberg, 2006).
To diagnose BDD, its DSM-IV-TR criteria cannot be better accounted for by another mental disorder, such as an ED. The similarities between ED and BDD can make assessment difficult. Both typically begin in adolescence and have a similar illness course. In addition to body image focus, both entail compulsive behaviors, such as strict diets, mirror checking, or body measuring. BDD sufferers can also be preoccupied with body areas that are characteristically seen as ED specific, such as stomach, hips, or thighs (Phillips, 2005).
Both ED and BDD patients typically do not see themselves as others do. Those emaciated with anorexia contend they look normal or overweight, whereas BDD sufferers contend their appearance is defective. Katharine Phillips, in The Broken Mirror, describes those with anorexia camouflaging with bulky clothing to stop others from discovering their thinness. BDD individuals also wear bulky clothing out of shame and to avoid subjecting others to their perceived hideous defect (Phillips, 2005).
If the only obsession is overall body weight, then the person likely does not have BDD. In BDD, there is a specific body part that is targeted as defective. BDD sufferers focus, in order of descending frequency, on their skin, hair, nose, stomach, teeth, weight, breasts, buttocks, eyes, thighs, eyebrows, overall appearance of face, legs, face size or shape, chin, lips, arms, hips, cheeks, and ears (Phillips et al., 2005). BDD can also involve a specific obsession known as muscle dysmorphia. Muscle dysmorphic individuals, typically men, believe they are too small and can never gain enough muscle. Some refer to this condition as “reverse anorexia,” yet it can be conceptualized as a form of BDD (Phillips, 2005).
Although the list of BDD foci includes body image concerns seen in EDs, the majority of foci are clearly not ED related. This long list is included here to demonstrate the idiosyncratic nature of BDD obsessions and to encourage clinicians to assess thoroughly when questioning patients’ body concerns. BDD sufferers feel profound shame for being obsessed with these body parts, shame that can prevent BDD patients from verbalizing their issues in treatment. BDD assessment tools can therefore assist in clarifying the diagnostic picture.
Assessment
Phillips (2005) has developed the Body Dysmorphic Disorder Self-Questionnaire (BDDQ) as a self-report screening tool. She provides versions for adolescents and adults. Consisting of four questions, it allows patients to reflect and write their answers without the stress of clinician presence. Since self-reports do not typically tell the whole story, this screen is best followed by an interview, especially if the person seems to be endorsing BDD symptoms.
The Structured Clinical Interview for the DSM (SCID) is a widely used assessment tool for psychiatric disorders. The SCID is administered by clinicians and detects criteria for each disorder. Phillips (2005) has developed a diagnostic module for BDD using SCID format, with different versions for adolescents and adults. The questions explore being worried about one’s appearance, preoccupation with appearance, and the effect preoccupation has had on the patient and patient’s family or friends. Clinicians also assess whether body preoccupation is solely about size and shape. If it is, the patient does not have BDD, but may have an ED. Some patients have shape and size concerns along with other body appearance issues, which could indicate the presence of both ED and BDD.
In addition to SCID results, other behavioral and cognitive characteristics of BDD can be useful to explore. Direct questions about the use of mirrors, time spent grooming, grooming rituals, or money spent on grooming can increase the patient’s awareness of the level of preoccupation and provide more data for diagnosis and treatment. Direct questions are also warranted about the following areas: use of hats, coats, makeup, or sunglasses; frequent changing of clothes to find the perfect camouflage outfit; sitting or standing a particular way or in a certain light to hide aspects of one’s appearance; frequent tardiness due to grooming, avoidance of social situations, or not leaving the house; frequent body measuring for size or symmetry; excessive exercise or dieting; reassurance seeking; frequent comparing of self to others; believing others, even strangers, are noticing or staring at the defect; depression, anxiety, panic attacks, and suicidal thoughts because of one’s appearance (Phillips, 2005).
Several of these behaviors are common to ED individuals as well, such as frequent body measuring, excessive exercise, and dieting. The important difference rests on the focus and goal of the behaviors. Are patients trying to become smaller (ED), and dieting, exercising, and measuring to that end? Or do patients believe their face is too wide and the dieting, exercise, and measuring are focusing on this instead (BDD)? Are patients attempting to look perfect (ED) or just normal (BDD)? The level of preoccupation, life interference, and the goals of the behaviors further help clinicians separate behaviors connected to an ED from concerns that are not part of an ED.
The similarities between BDD and OCD suggest that similar assessment tools may be effective. Similarities include obsessional thoughts that are interfering and difficult to control, and repeating behaviors that are difficult to stop. Although not part of the diagnostic criteria for BDD, studies suggest compulsions constitute part of BDD for more than 90% of sufferers (Phillips, Hollander, Rasmussen, Aronowitz, DeCaria, & Goodman, 1997). As such, the Yale-Brown Obsessive Compulsive Scale (YBOCS) was modified for BDD assessment (Phillips et al. 2005).
The BDD-YBOCS has been used as the primary outcome measure in most BDD treatment studies (Phillips, 2005, p.381). The test is a semi-structured interview allowing for further probing and discussion by the clinician. Because the BDD-YBOCS measures severity rather than strictly being a differential diagnostic tool, instructions indicate that clinicians must first be fairly certain the person has BDD and know which body parts are the foci. The SCID for BDD and the BDDQ can provide this background information. Then, the BDD-YBOCS can yield valuable information about obsessions, compulsions, insight, avoidance, and BDD severity (Ruffolo et al., 2006).
Presence of overvalued ideation predicts treatment outcome and informs the choice of pharmacological interventions. The clinician administered Overvalued Ideas Scale, OVIS (Neziroglu, McKay, Yaryura-Tobias, Stevens, & Todaro, 1999), has shown reliability and validity with OCD. Items address various aspects of the patient’s beliefs, such as strength, reasonableness, accuracy, extent of adherence by others, effectiveness of compulsions, insight, and belief duration. Clinicians may also administer the Brown Assessment of Beliefs Scale (BABS; Eisen, Phillips, Baer, Beer, Atala, & Rasmussen, 1998). It measures insight, assessing delusions across many psychiatric disorders, including BDD. By measuring delusionality, clinicians can identify how it might impact interventions, outcome, and prognosis (Eisen et al., 1998).
Of particular importance in assessing BDD is taking a thorough history of surgeries. Patterns may emerge that provide important diagnostic validation or discrimination for BDD, as well as its course.
For patients with co-occurring ED, a measurement tool which addresses both BDD criteria and other body image concerns is useful. The Body Dysmorphic Disorder Examination (BDDE) is a semi-structured interview designed to diagnose BDD and to measure symptoms of severely negative body image (Rosen & Reiter, 1996, p. 755). Rather than a screen, the authors suggest the BDDE be used to identify treatment goals by providing a detailed assessment and description of BDD symptoms. They developed the tool as clinician administered to help patients clarify their body image beliefs and thus identify what is BDD focused and what is not. In addition, the tool has been found to be reliable and valid for use with ED patients. Therefore, despite its 30 minute length, it has the potential to provide clinicians with valuable treatment information for intervening in BDD and EDs.
Diagnosing BDD in adolescents deserves special note. The difficulty with assessing BDD in adolescents is the normal, yet often drastic, increase in appearance concerns occurring during the teenage years. Because of this normative increase in appearance concerns, BDD is likely underdiagnosed in adolescents. Yet it is important to recognize the symptoms of increased and obsessional appearance focus early and establish treatment. Careful assessment of comorbid BDD in ED supports positive outcomes.
Phillips (2005) notes that developmental changes in the adolescent brain may contribute to the adolescent onset of this disorder. These changes increase adolescents’ self-consciousness and awareness of social status. Therefore, BDD may be a disordered response to the psychological, social, and physical changes of adolescence itself (Phillips, 2005). The clinician must tease out normative increased adolescent concerns from BDD concerns. To assist, the BDDQ and BDD SCID diagnostic module have adolescent versions. Phillips (2005) further suggests the same guidelines used for adults: Appearance concerns must be consuming and cause significant emotional distress or interfere with functioning; they must also be negative and focused on an “imagined defect” or “slight anomaly” (American Psychiatric Association, 2000). Phillips (2005) encourages clinicians to particularly consider the adolescents’ impairment in functioning. One must remember to translate the difficulties into the teen’s world experience. Adult job impairment and remaining housebound may become for the adolescent missing school, avoiding dates, or dropping out of extracurricular activities. Social isolation due to BDD could manifest itself through an increase in instant messaging, phone, or email use along with reduction of in-person social connections. It is vital not to dismiss these changes, or minimize them as normal adolescent behavior. By focusing on impairment, one can judge better if the extended time in the bathroom signals BDD or a normative increase in appearance concerns.
BDD Treatment
Since BDD is a chronic condition, patients who suffer from BDD need regular, long-term follow-up with their psychiatrists and therapists. Patients benefit from a collaborative treatment team approach. The importance of the treatment team cannot be underestimated. When treating BDD, it is essential to establish trust and rapport (Phillips, January, 2002). Patients must believe their treatment providers understand their condition and take their BDD seriously. They will typically not be responsive to reassurances that they look fine or that the problem is in their imagination. Patients need to be educated about BDD and reassured that it is a well-documented disorder that has known treatments. Establishing patient rapport in this manner is important to maintain treatment compliance over the long-term. Within six months of discontinuing treatment, 53% of patients with BDD relapse (Arthur & Monnell, 2005). Drop out and relapse are often related to lack of follow through or lack of connection with the treatment team.
The obsessive-compulsive nature of BDD intuitively suggests that treatments for OCD can be applied to BDD. Indeed, published practice guidelines for OCD include recommendations for treating BDD.
Practice Guidelines
The only published practice guideline addressing BDD, Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder (2006), comes from the National Collaborating Centre for Mental Health in London. This guideline recommends the Stepped Care Model, where interventions begin with the least intrusive approach and progress to the most intensive as needed. Steps one through five are directed toward outpatient settings; step six addresses inpatient treatment.
Step 1. Awareness and recognition should address the shame which often keeps patients silent about their distress. Emphasize the involuntary nature of their behaviors and a biological and psychological understanding of BDD.
Step 2. Recognition and assessment focuses on detection, targeted education, establishing a treatment plan, and development of a support network for patient and family. Detailed assessment occurs when patients have particular BDD risk factors, such as social phobia, OCD, an ED, or seek dermatological or surgical interventions for minor blemishes. For confirmed BDD diagnoses, Stage 2 emphasizes assessment for suicide risk, self-harm, and other common comorbid conditions.
Step 3. Management and initial treatment focuses on psychological interventions for symptom reduction. Clinical judgment aids in assessing the level of impairment and appropriateness of interventions suggested. For adults, interventions include individual or group cognitive-behavioral therapy (CBT), exposure with response prevention (ERP), medication such as a selective serotonin reuptake inhibitor (SSRI), or a combination of these treatments. Involving family in treatment should be considered. For children and adolescents, CBT is recommended with family and school involvement.
Step 4. Addresses comorbidity and complicating factors affecting successful outcomes in previous stages. For adults, CBT with ERP is again recommended, combined with an SSRI or alternate medication if one has already been prescribed.
Step 5. Addresses care of patients with very complicated comorbidities, severe functional impairment, and treatment resistance. Those individuals who show only partial responses at previous levels or who have relapsed are appropriate for Step 5. Interventions are the same as Step 4, but a team specializing in BDD is now needed to replace or supplement the initial providers.
Step 6. Encourages inpatient care or intensive treatment programs. These patients’ lives are at risk, as they present with much distress and severe self-neglect. Inpatient treatment programs specializing in BDD generally combine all of the practices mentioned above, with additional intensity and optional modalities.
Psychotherapy
Clearly, practice standards suggest CBT as the treatment of choice for BDD in order to change obsessive thinking patterns and learn alternative coping skills (Massachusetts General Hospital, 2005). If BDD is relatively mild, CBT alone may be a reasonable first-line treatment. CBT is effective in both individual and group formats for therapies such as psychoeducation, self-monitoring, ERP, relaxation training, and relapse prevention (Sarwer, Gibbons, Crerand 2004). It has been shown that a majority of people with BDD respond positively to CBT (Phillips, 2005, p. 212). The National Institute for Health and Clinical Excellence in the United Kingdom identifies both psychopharmacology and cognitive-behavioral therapy as efficacious treatments for BDD (National Collaborating Centre for Mental Health, 2006). It is, however, not yet known whether CBT is more or equally effective to SSRIs.
BDD psychoeducation allows patients to break the silence and may help diminish a sense of isolation. Patients learn to recognize the ineffectiveness of their compulsive behaviors to permanently relieve anxiety and shame. Through self-monitoring activities and assignments patients learn to identify irrational thoughts and related compulsive behaviors.
CBT involves challenging negative thoughts for their validity and accuracy and restructuring new rational beliefs. In BDD, when cognitive interventions precede behavioral interventions, outcomes typically are better. In addition to mitigating compulsive symptoms, CBT has demonstrated efficacy in reducing depressive symptoms, increasing insight, and improving overall body image (Phillips, 2005).
ERP begins with developing a fear hierarchy of difficult situations for which the patient would typically use a compulsive response to reduce fear (Allen, 2006). Habituation teaches sufferers that fear will eventually diminish, and may even be extinguished, without performing ritualistic behaviors. This process is often long and arduous but can produce excellent results. Establishing a hierarchy, being honest with self about rituals, and diligent self-monitoring are keys to successful treatment plans.
Mild to severe isolation is common to BDD and must be addressed in the treatment plan. Activity scheduling confronts isolation and challenges cognitive distortions that underlie isolative behaviors. As insight improves, patients consciously schedule activities that also qualify as exposure interventions, such as going out in public without makeup (Massachusetts General Hospital, 2005).
Mirror retraining directly confronts BDD sufferers’ selective attention. This process of over-focusing or over-attending to one area to the exclusion of other body parts hampers patient ability to keep the defect in perspective. The body part is over-emphasized and the reaction becomes extremely negative (Phillips, 2005). Some patients narrow their focus so intently that they can actually see the body part change in the moment (Phillips, 2005). Although some research suggests that selective attention in BDD may have a neuropsychological basis (Feusner, Granet, & Winograd, 2006 August; Phillips, 2005), behavioral interventions for selective attention seem effective in reducing symptoms and improving functioning. For example, patients seem to benefit from learning to stand an arm’s length from the mirror and from reducing the number of mirror checks they perform throughout the day (Feusner, Winograd, & Saxena, 2005).
Research shows several alternative interventions to be ineffective in treating BDD: supportive or insight oriented therapy, natural remedies, diet, hypnosis, reassurance, and uncovering suspected trauma. Each has been attempted without demonstrated successful outcomes (Massachusetts General Hospital, 2005). Dermatological and surgical treatments in particular are counterproductive for BDD. For example, 81% of BDD patients were dissatisfied or very dissatisfied with the results of surgery. Furthermore, 88% reported that non-psychiatric treatments for BDD defects led to no change or a worsening of the overall disorder (Phillips et al., 2005, p.323).
Psychopharmacologic Treatments
Between half and three quarters of BDD sufferers improve significantly with SSRI treatment (Phillips, 2005, p.212). Of those with BDD, 80%-90% eventually respond to one of the SSRIs. As such, psychiatric medication options should be considered for BDD, particularly when it proves to be refractory to CBT alone.
No medications have been FDA approved for treating BDD. Thus far, the most efficacious pharmacological treatment for BDD has been high-dose SSRIs, at doses similar to those used in OCD (Arthur & Monnell, 2005). The prescribing professional educates the patient about BDD and explains the costs, benefits, and alternatives to medications. Patients should be invested in treatment and be hopeful for success. In addition to communicating hope, enthusiasm, and empathy, practitioners present scientific, evidence-based information. Patients learn that they may need to use the high end of clinically effective medication dosing, which may exceed FDA-recommended dosages (Phillips, 2005). Treatment failures on psychiatric medications can often be attributed to under-dosing or an inadequate length of a medication trial.
Examples of common daily dosages used in BDD are: 40-80mg of Prozac (Fluoxetine), 40-60mg of Paxil (Paroxetine), 200mg of Zoloft (Sertraline), 60-80mg of Celexa (Citalopram), and 200-300mg of Luvox (Fluvoxamine). Phillips (2004) suggests aggressive trials with SSRIs, with rapid titrations to the maximally tolerated safe dosages as the first-line pharmacologic treatment of BDD. She suggests that these trials may take up to 16 weeks before reaching full benefit. Before positive benefits can be felt, patients may experience disturbing side effects. In some cases education about the benefits of the SSRI and direct intervention on the side effects may suffice. For other patients the side effects may be so intolerable or the benefits suboptimal that the physician will want to switch to an alternate SSRI.
Patients with BDD, on the whole, seem to tolerate the side effects of SSRIs fairly well, especially if psychiatric providers prepare them through psycho-education. Some typical side effects of SSRIs are nausea, sexual dysfunction, headaches, sedation, insomnia, and increased sweating (Stahl, 2006). Most of these side effects dissipate over time. BDD patients need to be encouraged to wait and see if these side effects eventually resolve.
If an SSRI proves to be ineffective in treating BDD or side effects prove intolerable, the next step would likely be to try another SSRI (Phillips, 2005). After multiple failed SSRI trials, the serotonin-norepinephrine reuptake inhibitors (SNRIs), such as Effexor XR (Venlafaxine) and Cymbalta (Duloxetine) are possible alternatives. SNRIs also have transient side effects similar to SSRIs. Another option is the serotonin-reuptake blocking, tricyclic antidepressant, Anafranil (Clomipramine) (Phillips, June, 2002). Anafranil can be used alone at doses of 150mg to 250mg, or as an adjunct to an SSRI. If used adjunctively, blood levels of Anafranil should be monitored to avoid toxicity and seizures. Because of weight gain and lack of tolerability in high doses, we seldom use Anafranil in Remuda’s Programs.
In cases when only a partial response is achieved, it is also reasonable to use other adjunctive medications with the SSRIs (Phillips, 2005). The use of antipsychotic medication has not been well established in BDD; however, if the thoughts associated with BDD are delusional in nature, one could add an antipsychotic, such as Risperdal (Risperidone), Abilify (Aripiprazole), Geoden (Ziprasidone), or Zyprexa (Olanzapine). Antipsychotics used alone do not seem helpful. Abilify or Geodon might be used preferentially over Risperdal or Zyprexa due to significant weight gain with the latter.
Anxiety symptoms are prominent in BDD. If they are not helped by an SSRI/SNRI with or without an antipsychotic, Buspar (Buspirone) at 30-60mg daily can be helpful to reduce their intensity. In addition, benzodiazepines, whether used for the short-term until the SSRIs take effect or for the long-term, can be helpful for agitated, severely anxious patients. The risk for dependency should be weighed against the benefits of symptomatic relief. Klonopin (Clonazepam), beginning at 0.5mg twice daily, may be an option because of its relatively long half-life and possible lesser potential for psychological and physical dependence than other benzodiazepines.
When treating children and adolescents with BDD, the same medications also work (Phillips, 2005). Special considerations involve working closely with parents to observe any untoward changes in the patient. Parents need to be warned of the possible increase in suicidal thinking that might be precipitated by the initiation of SSRI treatment. Children and adolescents need close monitoring by their psychiatric provider, initially weekly or bi-weekly until stabilized on their medications. Parents should feel free to call the psychiatric provider with any questions or concerns and take part in psychoeducation about the condition and its treatments.
Ethical Considerations
An ethical consideration of primary concern relates to proper diagnosis. Practitioners must be well informed about BDD diagnostic criteria, differential diagnosis, comorbidity, treatment guidelines, and efficacious medication regimes. BDD patients do not respond well to pat reassurances. This may give the impression that the practitioner does not take their concerns seriously or understand the depth of despair they encounter daily. Proficiency in BDD gained through specialized continuing education and supervision is therefore urged before one treats the disorder.
Patients need to be comfortable with the diagnosis of BDD. They need to know they have a clearly defined, well-documented condition that is amenable to CBT and medication treatments. It is important to emphasize that most patients with BDD get better with the appropriate course of treatment designed specifically for BDD (Phillips, 2005). Almost 75% significantly improve; of the rest, most get some relief; only a small minority do not get any better. The odds, therefore, are good that patients will improve. To increase their odds of success, treatment providers need to operate as a team, supporting each other by communicating their collaborative approach to patients and families. Teams should encourage patients to maintain treatment for the long-term, instruct them to take their medications consistently at the doses recommended and at the same time everyday, and enlist the help of family members and other interested parties when appropriate.
About half of all successfully treated patients with BDD relapse within six months after dropping out of treatment (Arthur & Monnell, 2005). Relapse prevention and ongoing care are therefore essential to ensure patients’ well-being. Relapse prevention work should be routinely built into treatment plans.
Spiritual Considerations
“May the Lord bring you into an ever deepening understanding of the love of God” (2 Thessalonians 3:5).
Spiritual issues related to BDD vary from fear and shame about body image to confusion about the nature of God. The perception of being unacceptable to others due to defective appearance carries fear and shame that can damage spirituality. It becomes easy to make assumptions that one lacks worth and value; is less than; is a distortion, if not a defective human being altogether. Conclusions may move from perceptions of the outer self to the inner self, and negative beliefs may become internalized. It is here, in this lonely, perplexing place that patients often struggle with thoughts and feelings about God.
The shame associated with BDD can create a desperate desire to hide from God and others. Isolation and feelings of shame go hand in hand. Those with BDD recognize that others do not perceive their defects as deformities. On one level they may understand that their beliefs about their appearance are irrational; on the other, they may feel misunderstood or abandoned by both God and others.
At times like this, healthcare professionals can be caught off guard. How can we help a patient struggling with the spiritual aspects of a disabling disorder? Healthcare professionals are in a strategic position to assist those searching and struggling with spiritual matters. Surveys indicate that two-thirds of Americans would like their healthcare providers to address religion with them, and half want their doctors to pray with them (Gunderson, 2000).
The healing of the spirit is essential for complete wholeness. One can heal physically and mentally and still have a broken spirit within. At Remuda, we treat the whole person, body, soul, social relations, and spirit. Some need only to be guided back gently to the arms of God. Some may need to see and experience the love of God again or for the first time through professionals who demonstrate God’s love and grace “with skin on”. Still others feel they need to ask forgiveness and experience redemption. Whatever the spiritual brokenness, we strive to guide people toward complete healing.
It is helpful to avoid debating physical imperfections and instead move to matters of the heart. Addressing patients’ innate worth and value can help to heal the broken places. BDD sufferers often believe they are inferior and unacceptable to the rest of the world. This is a great place to introduce Biblical truth. To begin, God does not view us as we view ourselves. Human beings look at the outward appearance but God looks at the heart (1 Samuel 16:7). In the Bible, we are reminded that our worth and value have nothing to do with being physically or aesthetically beautiful or perfect as defined by human beings.
Psalm 139:14, a familiar verse to those working with EDs, says: “I praise you because I am fearfully and wonderfully made: your works are wonderful.” Meditating on this truth can help heal a fragmented heart. God made us wonderful. What does that mean to those who perceive themselves as grotesque, who literally despise their bodies? What does it mean to hear that it was God who formed us? The implications this may have for the relationship with God are evident. There may be anger at God for afflicting the individual with what is perceived as a deformity. This anger can be expressed in therapy and prayer and ultimately lead to a place of greater self-acceptance. The goal is to transcend the outer perceptions and to see ourselves as God sees us, having great value and worth. It can be helpful to meditate on and appropriate for oneself the truth that we are made in God’s image; are “the temple of the living God” (2 Corinthians 6:16), that God’s Spirit dwells within us. These ideas call us to an intimate relationship with a God who created us in love and declared this creation “good” (Genesis 1:31), even “wonderful” (Psalm 139:14).
For many who suffer with BDD, acceptance is a core issue. God offers us his unconditional acceptance and love. To develop or restore a relationship with God, with accurate understandings, brings spiritual renewal. A right relationship with God brings many concerns back into perspective. The reality that the God of the universe has chosen to live within us reinforces the truth that we are of the greatest value and worth. For those who consider themselves “damaged goods,” this truth is difficult to grasp, yet to do so can bring long awaited healing. As this truth unfurls in our lives it brings greater self-awareness and self-acceptance. Grasping and holding fast to this truth through prayer, meditation, worship, spiritual readings, and other methods may restore hope.
In faith, we journey together with our patients to better comprehend the great love God has for us and to find acceptance of ourselves through the One who made us. The journey for someone with BDD may not be easy; but with the assistance of appropriate medication and psychotherapy, those with BDD may be ready to wrestle with the deeper spiritual question of why God made them as they are, seeking their identity in his love and finding there a refuge of self-acceptance, peace, and one day joy in their skin.
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