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    EMDR in the Treatment of Body Image Issues (Body Dysmorphia)

    Body Dysmorphia is a condition in which individuals are preoccupied with perceived defects or flaws in their physical appearance causing them to believe they look ugly, unattractive, abnormal, or deformed.  Body Dysmorphic Disorder (BDD) represents a severe manifestation of this condition and is present in 2.4% of the US adult population. But we must also take into consideration the vast majority those who may not have symptoms severe enough on the spectrum to warrant the full “disorder” yet still struggle in their daily lives with major mental health challenges related to how poorly they may view their bodies.


    According to one study3, body image dissatisfaction was present among 77.6% of university women. Another study1 found that 36.7% of university-aged students were dissatisfied with their bodies, with a higher level of body image dissatisfaction among men.  According to the National Organization for Women6, 78% % of American girls are unhappy with their bodies by age 17, while 45.5% of teens 43.7% of women over 60 report considering plastic surgery.  And a survey5 done in the UK showed that among teenagers, 37% felt upset and 31% felt ashamed in relationship to their body image, about a third of adults felt anxious or depressed related to their body image, 19% of adults felt disgusted by their body image in the last year, while 13% of adults experienced suicidal thoughts or feelings because of concerns about their body image. This is an issue that is cross-cultural, can lead to severe emotional distress, major mental health conditions, eating disorders, substance abuse problems, and suicidal ideations, and is therefore deserving of effective, therapeutic intervention.

    Common Body Dysmorphia Manifestations

    With body dysmorphia, some of the most common areas of focus include the face (nose, blemishes, complexion, acne, etc.) hair, skin, breast size, muscle size and tone, being overweight.  Common symptoms of body dysmorphia include:


    • Extreme preoccupation with a perceived flaw or flaws in appearance that others can’t see or that seems minor
    • A rigid belief that this defect you have makes you look ugly, defective, or deformed
    • A belief that others see you in a negative, judgmental way as a result
    • Needing constant reassurance from others about your appearance
    • Behaviors aimed at hiding or fixing the perceived flaw such as excessive grooming, skin picking, checking in the mirror, over-exercise, excessive styling or makeup
    • Having perfectionistic tendencies
    • Social isolation or withdrawal

    Issues with poor body image can occur in both females and males, though there is a stigma associated with men having body image concerns.  As a result, men are less likely than women to talk about or get help for these issues.  Some of the recent terms coined for these issues in men, often concerned with thinness or muscularity, include “muscle dysmorphia” and “bigorexia” and can lead to exercise addiction and poor mental health.

    Common Treatments for Body Dysmorphia

    A traditional first-line treatment for Body Dysmorphia is Cognitive-Behavior Therapy (CBT) which focuses on addressing the negative thoughts, emotions, and behaviors that maintain this condition over time.  CBT seeks to challenge automatic negative thoughts about one’s body, learning alternate ways to manage compensatory rituals such as obsessively looking in the mirror and seeking reassurance from others, while teaching other coping skills to manage distress and mental health.


    Medication is also commonly prescribed for Body Dysmorphic Disorder, mainly antidepressants such as Selective Serotonin Reuptake Inhibitors, or SSRI’s.

    Utilizing EMDR for Treatment of Body Dysmorphia and Poor Body Image 

    Many clinicians who have tried the traditional top-down approaches to treating clients with poor body image experience substantial frustration and obstacles to improvement.  Often, helping clients find rational evidence to the contrary of these fixed, negative beliefs about their bodies is ineffective (or only temporarily effective) with treatment plans lengthy and slow-moving.  For those who have severe Body Dysmorphia, it is extremely difficult to convince a person that their thoughts about themselves and their projections regarding what others think are irrational.  For many clients, on an intellectual-level they already know that they and their bodies are “good enough” yet, on a gut-level, feel deeply inadequate or flawed.


    EMDR therapy represents an effective, alternative solution to treating Body Dysmorphia and body image concerns.  Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based, comprehensive psychotherapy founded in the 1980’s and grounded on the premise that current psychopathology is the result of maladaptively-stored, insufficiently-processed traumatic memories.  In EMDR therapy, treatment entails searching for the adverse experiences at the root of a client’s psychological condition and reprocessing them to adaptive resolution.


    One study2 described numerous cases of Body Dysmorphic Disorder treated with EMDR leading to improvements in six of seven patients, five of whom having a complete resolution of their symptoms. The authors noted that many of the patients in the study had intense, intrusive visual imagery similar to what is experienced in post-traumatic stress disorder, with many of these being intrusions being reflective of their supposed deformities or of the reactions of others to them.  In most of the cases, there were incidents that occurred prior to the onset of symptoms.  These precipitating events were often successfully targeted and resolved with EMDR.


    Dalene Forester wrote about of the use of EMDR in the treatment of body dysmorphia and poor body image in a chapter of Robin Shapiro’s edited book, EMDR Solutions II4.  Forester discusses her method of gathering a history of the client’s developing awareness of the body image issue or perceived flaw, using the three-pronged protocol to identify (a) past traumatic events, (b) past incidents of teasing, shame, and humiliation, (c) present triggers, and (d) the development of Future Templates.  The standard EMDR protocol is used to reprocess these treatment targets leading to an improvement in body image.


    I have had many positive experiences in my own practice in treating clients with pervasive negative beliefs about their bodies using similar approaches as in the two papers previously discussed.  Common past targets for EMDR reprocessing include past traumas that occurred around the onset of symptoms (often, but not necessarily related to their bodies), past experiences of criticism and teasing (for example, an older sibling repeatedly telling a client they are fat or ugly), past body image messaging in the client’s family of origin (sometimes overt but sometimes quite subtle), and past experiences related to media portrayals of body image and the client’s internal judgments of themselves.  Current triggers to be desensitized include being in public, going on dates, shopping for clothes, getting naked in front of a partner, etc.  You can also target the client’s body itself, allowing access to various related channels of association and often creating positive shifts in self-perception.   And following the work of the great Jim Knipe, it can also be helpful to target the maladaptive positive affect held within memories where the client was excessively praised for losing weight, being thin, or appearing a certain way.  These are some of the strategies I have found helpful in the treatment of poor body image with clients.  It’s a great feeling to help your client go from spending hours a day on makeup, looking the mirror compulsively, and avoiding interpersonal relationships to a life with more freedom, confidence, and self-acceptance.

    Conclusion

    There are many factors influencing negative body image in society—media images, familial messaging, unrealistic societal ideals, to name a few.  Individuals who struggle with how they perceive their bodies to look may experience significant mental health problems including anxiety and depression, low self-esteem, eating disorders and substance abuse issues, and even the potential for suicide.  EMDR represents a robust option for the effective treatment of this condition.




    Schedule an Appointment for EMDR Therapy in Delray Beach, FL 

    At Mangrove Therapy Group, all of our clinicians are trained in EMDR therapy and ready to help you with your body image concerns.  To start your therapy journey, please follow these simple steps:


    1. Alharballeh, S., Dodeen, H. Prevalence of body image dissatisfaction among youth in the United Arab Emirates: gender, age, and body mass index differences. Curr Psychol (2021). https://doi.org/10.1007/s12144-021-01551-8

    2. Brown, K., McGoldrick, T., & Buchanan, R. (1997). Body Dysmorphic Disorder: Seven Cases Treated with Eye Movement Desensitization and Reprocessing. Behavioural and Cognitive Psychotherapy,25(2), 203-207. doi:10.1017/S1352465800018403

    3. Ganesan, S., Ravishankar, S. L., & Ramalingam, S. (2018). Are Body Image Issues Affecting Our Adolescents? A Cross-sectional Study among College Going Adolescent Girls. Indian journal of community medicine : official publication of Indian Association of Preventive & Social Medicine, 43(Suppl 1), S42–S46. https://doi.org/10.4103/ijcm.IJCM_62_18

    4. Forester, D. (2009). Image is Everything: The EMDR Protocol in the Treatment of Body Dysmorphia and Poor Body Image.  In R. Shapiro (Ed.), EMDR Solutions II (pp. 165-174). W. W. Norton & Company.

    5. Mental Health Foundation. (2022, April). Body Image Report – Executive Summary. Retreived from https://www.mentalhealth.org.uk/publications/body-image-report/exec-summary

    6. National Organization for Women. (2022, April). Get the Facts. Retrieved from Get the Facts | National Organization for Women (now.org)