In the last section, we discussed three common aspects that fuel automatic thoughts found in BDD clients.  These three common aspects that fuel automatic thoughts included:  trigger events; core beliefs; and cognitive errors.

In this section, we will examine three aspects of family members of BDD clients.  These three aspects of family members of BDD clients include: feelings of neglect; angry parents; and education.

3 Aspects of Family Members of BDD Clients

♦ 1. Feelings of Neglect
The first aspect of family members of BDD clients is feelings of neglect.  Clients diagnosed with BDD often focus on their perceived defect to the neglect of their spouses and family members.  This can cause obvious strain in the relationship as the family members or spouses begin to feel more and more ignored. 

In a marriage, this aspect can be particularly damaging.  The spouse’s needs are not being met and they in turn begin to experience low self-esteem and feelings of worthlessness.  The spouses begin to view the client as selfish and unfeeling.  This sometimes makes it difficult to incorporate the client’s family member into therapy as they may resent the client’s behavior.  I find that educating spouses and family members can facilitate their help in the treatment.

Case Study: Samantha and Bill
Samantha, age 42, was married to Bill who was feeling neglected and secondary to his wife’s obsession with her nose.  Bill stated, "There aren’t enough days on a calendar to tell you how many times I’ve wanted to leave my wife.  I’m a very loyal person and I love her.  But at times it gets to be too much!  She’s late when we go out, and sometimes she won’t go out at all!  She can get so wrapped up in her obsessions that she ignores me completely.  She doesn’t give the children the attention they need.  BDD is the selfish disease." 

I stated to Bill, "Bill, you’re feeling pushed aside and you’re needs are not being met.  Have you ever spoken to Samantha about how you feel?"  Bill stated, "No, I haven’t really.  I just assumed she didn’t care." 

Samantha then chimed in, "I knew!  I already knew!  I just couldn’t do anything about it, I don’t know how!"  Bill stated, "I guess I never thought that it would matter to her."  Think of your Bill.  Would some acknowledgement from his or her partner help them become more supportive?

♦ 2. Angry Parents
The second aspect of family members of BDD clients is angry parents.  I have noticed in my years practicing with adolescent BDD clients that parents of these clients do not know how to cope with the behavioral difficulties that often accompany BDD.  For instance, clients whose grades suddenly drop may be subject to severe punishment which further confirms their worthlessness and worsens their low self-esteem. 

Sometimes parents do not even realize that their son or daughter is experiencing the characteristic signs of BDD.  Because of this lack of understanding, they are not equipped to help their teen.  They try to use normal tactics that are not only ineffective, but may also worsen the client’s condition. 

Jenny, age 17, believed her hair to be too limp and stringy.  Her mother, Christine, tried everything to get her daughter to understand that she was beautiful.  Christine stated, "I knew something was wrong with my daughter when she’d be in the bathroom for an hour and was upset when she came out.  We’d tell her that she looked fine and to stop griping!  It was ruining her life!  All she did was stare in the mirror!  Her grades started falling and she wouldn’t go out with her friends anymore.  Grounding didn’t help either.  No matter what I threatened her with, she kept on staring into that goddamn mirror!" 

I stated to Christine, "Punishing Jenny will not stop her from believing that her hair is ugly.  In fact, it may only encourage the behavior.  The more you hurt her confidence and self-esteem, the more she will believe that she is ugly on the inside and outside."  Think of your Jenny.  How does his or her parent unknowingly worsen their teen’s BDD symptoms?

♦ 3. Education
In addition to feelings of neglect and angry parents, the third aspect of family members of BDD clients is education.  I have found, as I’m sure you have as well, that educating the parents and family members of BDD clients becomes essential in preventing detrimental behavior that only encourages rituals. 

Because BDD is such a misunderstood disorder, it is very likely that family members have never come across it.  Because of this, they try to circumvent the client’s frustrations by reassuring them and encouraging them to participate in activities that only increase their anxiety and thus cause them to ritualize.  By educating parents, spouses, and other family members, it becomes easier to provide a support system and environment that is beneficial to the client and furthers their treatment.

Technique:  The Thirteen Commandments 
To help clients like Samantha and Jenny have a more fulfilling family life, I provide his or her family members with the Thirteen Commandments that provide helpful guidelines to treating a person with BDD.  Listen to these guidelines carefully.  What would you change?  What would you keep the same? These Thirteen Commandments include the following:

1. Recognize BDD symptoms, take them seriously, and talk openly about BDD.
2. Don’t discuss the "defect" or try to talk the person with BDD out of their beliefs about their looks.  This approach is never effective and makes everyone frustrated.
3. Create a supportive home environment.  Help your family member with BDD talk about his or her feelings of anxiety and fear, without being judgmental or critical.
4. Limit your involvement with rituals.
5. Don’t give reassurance. Reassurance seeking is a BDD ritual and taking part only encourages the use of it. 
6. Encourage better functioning, but also recognize the person’s limitations.  If your family member is in the beginning stages of his or her exposure program, do not force him or her to go beyond those stages yourself.
7. Encourage participation in family events.
8. Give praise for small gains.
9. Look at the Big Picture.
10. Limit angry outbursts.
11. Take suicide threats seriously.
12. Keep your family routine as normal as possible.
13. Don’t blame yourself.

Think of your BDD client.  Could his or her family members benefit from these Thirteen Commandments as a helpful guideline?  Would playing this se in a session be beneficial?

In this section, we discussed three aspects of family members of BDD clients.  These three aspects of family members of BDD clients included: feelings of neglect; angry parents; and education.

In the next section, we will examine three aspects of depression in BDD clients.  These aspects of depression in BDD clients include:  similarities, differences, and feelings of worthlessness.

- 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:
Baker, J. H., Higgins Neyland, M. K., Thornton, L. M., Runfola, C. D., Larsson, H., Lichtenstein, P., & Bulik, C. (2019). Body dissatisfaction in adolescent boys. Developmental Psychology, 55(7), 1566–1578.

Cheng, H.-L., & Mallinckrodt, B. (2009). Parental bonds, anxious attachment, media internalization, and body image dissatisfaction: Exploring a mediation model. Journal of Counseling Psychology, 56(3), 365–375.

Hitti, S. A., Avila, M., McDonald, S. E., Romo, S., Benzel, G. K., Hernandez, R. E., Vazquez, G., Sullivan, T. N., & Corona, R. (2020). The relation between body image perceptions, parental messages, and depressive symptoms among Latinx college students. Cultural Diversity and Ethnic Minority Psychology, 26(3), 412–418.

Patton, S. C., Beaujean, A. A., & Benedict, H. E. (2014). Parental bonds, attachment anxiety, media susceptibility, and body dissatisfaction: A mediation model. Developmental Psychology, 50(8), 2124–2133.

Wilver, N. L., & Cougle, J. R. (2019). An Internet-based controlled trial of interpretation bias modification versus progressive muscle relaxation for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 87(3), 257–269.

QUESTION 15
What are three aspects of family members of BDD clients? To select and enter your answer go to Test.

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