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Section 13
Social Anxiety Symptoms

Question 13 | Test | Table of Contents

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In the last section, we discussed three triggers of BDD symptoms.  These three triggers of BDD symptoms included:  comments; stress; and grudges.

Like clients with phobias and obsessive compulsive disorder, BDD clients must commit to exposure therapy. However, unlike phobic and OCD clients, BDD clients must face more than just an irrational fear.  BDD clients must face the idea of their worthiness and self-esteem.

In this section, we will examine three difficulties in exposing BDD clients to anxiety-provoking situations.  These three difficulties in exposing BDD clients to anxiety-provoking situations include:  social anxiety; self-esteem; and behavioral experiments.

3 Difficulties with Exposure to Anxiety-Provoking Situations

♦ 1. Social Anxiety
The first difficulty in exposing BDD clients to anxiety-provoking situations is social anxiety.  While phobic clients may have more specific situations to avoid, BDD clients are constantly dogged by the fear of being around people.  They fear that others will judge them and so avoid any contact with large groups of people.  This makes exposure even more difficult because almost every aspect of a healthy lifestyle must include interaction with others.  The gradual moving up the hierarchy can be difficult to control. 

For instance, if a client states that her lowest anxiety-provoking situation is going to the mall, but her highest anxiety-provoking situation is facing someone within a foot, how does she prevent the highest anxiety situation from accidentally occurring during her lowest anxiety situation? 

♦ Exposure Therapy
Johnny, age 38, was overly preoccupied regarding his small physique.  To begin Johnny’s exposure therapy, I asked him to rank his anxiety-provoking situations from least difficult to most difficult.  One of his least difficult exposure situation was "going to my family’s house" and his most difficult exposure situation was "talking to a woman."  When Johnny exposed himself to his parents’ house, he didn’t realize that they were having friends over and one of them was a woman Johnny’s age who his mother wanted him to date. 

Obviously, this situation was highly stressful... for Johnny.  He called me from his cell phone outside of the house when he found an opportunity to excuse himself.  He stated, "I can’t stand it!  They keep bringing the conversation back to me and dating!  I can’t take all the attention!"  Normally, if only one anxiety situation presents itself, I discourage quitting until the anxiety has at least slightly subsided. 

However, because Johnny was only beginning his exposure therapy, I found it appropriate that he excuse himself from the situation before his anxiety became too much.  I stated, "This is not part of our plan, and so you are not backing out of your primary situation but rather a situation that you cannot handle yet.  It’s perfectly fine if you leave."  Think of your Johnny.  How would you advise him or her if exposure situations of varying difficulties overlapped?

♦ 2. Self-Esteem
The second difficulty in exposing BDD clients to anxiety-provoking situations is self-esteem.  Normally, clients with OCD and phobias may be able to overcome their initial anxiety with confidence. 

However, BDD clients experience severely low self-esteem which greatly increases their risk for ritualizing.  Because they are not comfortable with themselves, they may find it extremely difficult to be comfortable in exposure situations.  The client’s identity has become so completely immersed in the idea of appearances that he or she may experience feelings of confusion and unworthiness during exposure. 

Because of this, I find it useful to also use self-esteem behavioral exercises in addition to exposure methods in order to bolster a client’s willingness to accept exposure therapy. 

♦ Technique:  Compassionate Image
Fred, age 43, believed that his belly-button was ugly.  He stated, "I never go to the beach and I can’t take my shirt off.  Not even in front of my wife.  When we have sex, I just leave my shirt on and it drives her crazy!"  To help clients like Fred become more exposed to his anxiety, I asked him to try the "Compassionate Image" Exercise.  This exercise includes the following list of instructions which I gave to Fred.  Listen to them carefully and decide whether or not you think this would be a beneficial exercise for your BDD client.

  1. Stand comfortably before a mirror and slowly scan your whole body as if your were seeing it for the first time.  Slowly let your eyes move from your feet upward, and ask yourself how you feel about what you’re seeing.
  2. Choose an area of your body that you like because you think it’s quite attractive.  Focus on it and admire this attractive feature.  Try to think of one word that best describes that part of your body.  Then close your eyes and visualize that part, just as it looks in the mirror. 

I then asked Fred to begin his exposure therapy by talking to his wife without his shirt.  Think of your Fred.  Could he or she benefit from  "Compassionate Image" Exercise?

♦ 3. Behavioral Experiments
In addition to social anxiety and self-esteem, the third difficulty in exposing BDD clients to anxiety-provoking situations is behavioral experiments.  As you already know, developing behavioral experiments for BDD clients can be especially difficult if the client cannot easily measure the responses of others during his or her experiment. 

Generally, I have found that by exposing the client to a situation in addition to a behavioral experiment also aids in the cognitive restructuring process.  Many times, a BDD client’s greatest concern is with how others are viewing him or her and if they are judging him or her.  In most cases, this forms the central theme to my behavioral experiments with BDD clients.

Juan, age 31, believed that his skin was "beet red" and that his hair "looked really weird and stuck out all over the place."  He believed that his face was so red and his hair looked so strange that he stood out in a crowd and that people took special notice of him.  Juan allowed his hair to grow long so that he could camouflage his beet red face.  To help Juan, we designed a hypothesis.  Juan stated that because his hair and skin looked so bad, that if he went into the  grocery store, eighty percent of people would look at him with disgust and move away from him within five minutes. 

Before carrying out this experiment, I discussed the likelihood that people would move away from him due to personal space issues as well as not wishing to bump into him.  I also suggested that Juan complete this experiment with his girlfriend Maria who can more objectively observe other people.  

During the experiment, they observed that about thirty percent of people didn’t move at all when they were around Juan.  They seemed to be busy deciding what food they wanted to buy.  About forty percent of people moved away from Juan, and about thirty percent moved toward him.  Neither Juan nor Maria observed any looks of disgust, even fleeting ones.  Think of your Juan.  What behavioral experiment could you create for him or her?

In this section, we discussed three difficulties in exposing BDD clients to anxiety-provoking situations.  These three difficulties in exposing BDD clients to anxiety-provoking situations included:  social anxiety; self-esteem; and behavioral experiments.

In the next section, we will examine three common aspects that fuel automatic thoughts found in BDD clients.  These three common aspects that fuel automatic thoughts include:  trigger events; core beliefs; and cognitive errors.

- Junne, F., Zipfel, S., Wild, B., Martus, P., Giel, K., Resmark, G., Friederich, H.-C., Teufel, M., de Zwaan, M., Dinkel, A., Herpertz, S., Burgmer, M., Tagay, S., Rothermund, E., Zeeck, A., Ziser, K., Herzog, W., & Löwe, B. (2016). The relationship of body image with symptoms of depression and anxiety in patients with anorexia nervosa during outpatient psychotherapy: Results of the ANTOP study. Psychotherapy, 53(2), 141–151.
Reviewed 2023

Peer-Reviewed Journal Article References:
Combs, D. R., & Tiegreen, J. (2007). The use of behavioral experiments to modify delusions and paranoia: Clinical guidelines and recommendations. International Journal of Behavioral Consultation and Therapy, 3(1), 30–37.

MacKenzie, M. B., & Kocovski, N. L. (2010). Self-reported acceptance of social anxiety symptoms: Development and validation of the Social Anxiety—Acceptance and Action Questionnaire. International Journal of Behavioral Consultation and Therapy, 6(3), 214–232.

Newman, S. (2020). Review of Clinical evolutions on the superego, body, and gender in psychoanalysis [Review of the book Clinical evolutions on the superego, body, and gender in psychoanalysis, by J. S. Lieberman]. Psychoanalytic Psychology, 37(1), 86–87.

Ryding, F. C., & Kuss, D. J. (2020). The use of social networking sites, body image dissatisfaction, and body dysmorphic disorder: A systematic review of psychological research. Psychology of Popular Media, 9(4), 412–435.

Stapleton, P., Crighton, G. J., Carter, B., & Pidgeon, A. (2017). Self-esteem and body image in females: The mediating role of self-compassion and appearance contingent self-worth. The Humanistic Psychologist, 45(3), 238–257.

Summers, B. J., & Cougle, J. R. (2018). An experimental test of the role of appearance-related safety behaviors in body dysmorphic disorder, social anxiety, and body dissatisfaction. Journal of Abnormal Psychology, 127(8), 770–780.

QUESTION 13
What are three difficulties in exposing BDD clients to anxiety-provoking situations? To select and enter your answer go to Test.

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