How has brain research contributed to treatment of body dysmorphic disorder? This transcript including my internal dialogue helps explain how in depth knowledge of the brain can assist in treatment.


“I’ve been suffering with BDD for about four years now but in the past two years it’s become unbearable”

She says to me as we sit down together in the interview room.

“I honestly feel like the ugliest human alive and its ruining me. I feel so much disgust when I catch a glimpse of myself in the mirror.”

I write down the word “glimpse” on my notepad, and wonder if this is an expression of the incomplete view of her face, mediated by problems with the integration of the visual systems.

“I just feel so ashamed that other people have to look at me, so I don’t go out much. When I’m at home I sit upstairs so my family doesn’t have to look at me. I know they think I’m ugly, I can tell, though they don’t say it to my face”

“How can you tell they think you’re ugly?” I’m hoping she won’t misinterpret the question, or my neutral facial expression as judging. I jot down her response, remembering that the amygdala activity caused by sharing her story might spill over into emotional misperceptions.

“The only way I feel bearable to let people see me is when I’m caked in makeup, fake tan, eyelashes and hair extensions and even then I still feel deformed. It has gotten so bad that I won’t even answer the front door. When I hear the doorbell I hide upstairs till they have gone.”

The mention of the doorbell reminds me of Pavlov’s dogs and classical conditioning. I wonder if I played her doorbell sound here she would become anxious. I write a note to remind myself that ringing the doorbell could be a target for exposure and response prevention, and wonder, given the compromised connections between the orbitofrontal cortex and the amygdala, how long it would take for extinction to occur.

I ask, “What have you tried so far to cope with these feelings?”

“Friends have suggested a few different things. I should look at myself in the mirror less, more…whatever. Another told me to go out with the mentality of “who cares what they think”. I walked down an empty street and it seemed to work fine but as soon as I saw another person glance in my direction instantly I was thinking oh God they think I’m hideous. So that one failed as well.”

Thinking about the inhibitory control the frontal regions have over amygdala reactivity I say, “That was a brave thing to do, walk down the street like that. But the fear was too much. You couldn’t just talk yourself out of it. The emotions were too strong and came too quick”.

“I constantly compare myself to every other girl I see and I spend most of my time reapplying makeup. I just look in the mirror and try different shades of makeup, but nothing works. I don’t even think surgery would help me because my face is that bad.”

“It seems like you’ve tried a few things that haven’t worked so far. I wonder if checking in the mirror and putting makeup on gets you into a bit of a cycle?” I suggest, keeping the cortical-striatal-thalamic-cortical circuit in mind.

“Yes, but I can’t stop thinking of how I look. Sometimes I try to block out the thoughts but then I get this overwhelming sense that something is wrong.”

I nod, “like your brain is sending you this signal that something just isn’t right?”, thinking about dysfunction in the anterior cingulate cortex and error detection circuits.

“My parents don’t know; I am suffering alone. I just hope I will get out of it because I just can’t keep going anymore and there is no reason for waking up in the morning. I can’t believe it has taken me so long to admit this, but I have to admit it to someone. I have finally decided to get counselling”