Multiple Anxiety Disorders Great Dunmow, Essex
Diagnosed: Body Dysmorphic Disorder. Highly Avoidant. (Client lives in Great Dunmow, Essex)
"Dan" (not his real name) is 31 and works as a Sales Manger. Dan came to see me about eight months ago, having been given a diagnosis of Body Dysmorphic Disorder (BDD).
Our first session was difficult. Dan was very anxious, he couldn't make eye contact, his legs were shaking furiously, and his chin was firmly to his chest.
Dan had received Cognitive Behavioural Therapy (CBT) for his BDD about six months previously. It seemed to help him. But he felt the problems, such as constant checking in the mirror had begun to resurface. When I probed further, we uncovered other problems – he hated getting dirty, he feared contamination. For example, he told me he’d once freaked out in a supermarket, when a bottle of sauce was smashed and got on his clothing.
Dan had had a few problems at work, mainly because he’d been going out of his way to avoid important meetings. He had used his daughter’s illness – she has a degenerative condition and needs close care – to excuse himself from going to these meetings. And this was resulting in increased pressure at work
He’d stopped socialising, with anyone outside of the family. He had given up hobbies, including DJ-ing, which he had been very passionate about, and was becoming increasingly dependent on his family – mum, dad, sister, wife – for emotional support; getting them to reassure him, several times a day, that he looked OK, and wasn’t grotesque.
In particular, Dan felt that his teeth were crooked and ugly. He was also obsessed with his hair being a certain way – and, of course, a trip to the hairdresser risked having to see himself in the mirror.
When he did look at himself in a mirror, it had to be in dimmed light; never in natural daylight
Dan told me of an incident when his sister asked him to pop to the shops to buy some milk. He reacted angrily, telling her he was tired but in fact he was more concerned about getting his hands and clothes dirty if he went out and also that people would see his “awful” teeth. When his sister confronted him with this alternative explanation, he was shocked. The story indicated that he had less awareness than some of his family members of what some of his behaviours meant.
His loving family were very supportive. But there is a fine line between support and dependency, and we examined this in detail in therapy.
Dan had not developed any useful coping skills. His parents regularly took charge of his children, paid for holidays, reassured him automatically that he looked ok, and the close-knit nature of the family structure meant that outsiders rarely infiltrated the safety of the unit; they functioned as a unit. “I remember my friends calling us 'The Waltons'. we used to go everywhere together and others thought it was odd that we spent so much time together as a family”, he said.
To improve his chances of not relapsing he needed his family to understand why the problems were being maintained and, more importantly, his family's role in maintaining them. We needed to use the supportive nature of the family structure to identify his more subtle safety behaviours. To “shape” his environment – that is to change the way his family reacted and responded to him.
The family unit was mobilised to monitor triggers and activating events, and to keep a record and to show Dan how he was subtly avoiding and seeking reassurance.
Snap and Click
I asked Dan to put a rubber hand around his wrist and whenever he felt the urge to check in the mirror (other than once in the morning and once before bed) then he was to snap the rubber band hard. Find this hilarious, he was very motivated to try it. “My wife keeps wanting to snap it for me when she notices me checking, we laugh about it but I am very aware now of when it’s happening”. I asked Dan to use a tally counter and click every time he noticed an urge to get reassurance.
This interaction from family members in a positive way has been the key to Dan moving forward.
I've encouraged Dan to take up his old hobby of DJ-ing. He began to do this at home first and was soon working in a local bar as a DJ one or two evenings a month.
Over the ensuing weeks, his social phobia had reduced significantly and because he was passionate about his hobby, he found himself socialising with a wider group of friends outside of the family network. He was promoting himself on Twitter and Facebook, and interacting with confidence.
His family supported him in reducing his avoidance and reassurance seeking and his mother has found it less necessary to call him several times a day, and hardly at all when she's on holiday.
His BDD reduced enough so that we could increase Dan's exposure to looking at himself in a full length mirror in good daylight. He's more comfortable with it now.
He is far more resilient and aware of his relapse signals.