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Body dysmorphia: Exposure and response prevention

Permanent Linkby margharris on Thu May 21, 2015 12:53 am

Havent forgotten this blog. Just had trouble losing posts with some issues on Mozilla.

Exposure and response prevention was mentioned in the forum and as it is relevant to us today I thought I might make a reply with my two cents.
Historically ERP was designed for OCDer. It was the variety of contamination fears that had people put their hands in garbage. Not all that relevant to everyday living.
It was hard to find any therapist who had any knowledge of what to do. No one was immersed in the disorder enough to really know much more than the theory. Practice had a lot of shortfalls.
I can remember during one hospital stay, simply demanding that the psychs just try ERP on my son as handing out sheets on what anxiety was, was truly pointless.
Well the ERP didn't go well. They had no experience. After a half hour session standing in front of the mirror. He was supposedly practiced with control so they handed him scissors to place in his back pocket. A very panicky nurse rang me up later in the day to take him to a hairdresser. He had attacked his hair. Even with my limited knowledge I likened what they had done to giving an alcoholic a flask in a back pocket.
So from our experience set up exposures are more miss than hit. But there is a place for them when avoidance gets out of hand. My son now can give himself panic attacks over having a shower. This is no primal circuit operating but a learnt fear. If I change the cost benefit analysis and say he gets a Propecia tablet after a shower, I can get a shower. His thinking I believe is just being distracted by the expected reward so the anticipating fear is reduced. You just can't really think of two things at once. So this is more a distraction approach.
It works in the short term but doesn't do much at all for his own executive functioning. He is not doing the thinking himself to get him in the shower and that should be the goal.
A pressing problem also is his refusal to wash his hair. Not sure really if it has been really washed this year. The longer it goes the harder it is. I suggested a little drizzle of water as a starting step. But even this is felt as a strong anticipatory fear. When your BDD is this bad, the avoidance is so strongly felt that you really cant force it. Forcing is just met with counter resistance. I have allowed this to go on maybe too long. Really hoping the meds might make a more confident person to deal with. So I know he needs an exposure to deal with this but not sure he is medically ready. The willingness should be coming from him. I feel I need to wait for that to arrive.
Avoidance issues are also only the negatives he does. There are a host of compulsions that need what I call urge restriction and reduction. This is all the stuff he does but shouldn't do.
I made a list of all his compulsions early on in this blog. Haven't checked in with him to see how that is fairing. He has been too bedridden to be doing them. There are no mirrors for checking and no scissors. Online browsing and checking others for hairdos seem to be a bit less. He has mentioned friends who he described as ugly who had great partners. He explained that he knew his BDD thinking was all wrong. That is a perspective change that wasn't there a couple of months ago.
Still we are no more functional. Postponing or opting out is frequently preferred over doing. The battle lines shift but the battle just moves to another front. Yesterday he did go and do a small shopping list. He came back mentioning how many children were at the shops. I take from that that he wasn't looking at hair. I am probably too tired of this to register how much progress that might indicate but I have got to face up to tomorrow.
So in summary, I have been stuck in this exacerbation now for 16 months. If ERP was easy enough to do we would have found a way. My son is just too unwell and too unwilling. The hero who really wants to be a conqueror has to self initiate. He is a hero to live with this but still not the conqueror to fight it. Fear is too strong a motivator.
Hope we are helping those who are following. Thanks for your support. Marg

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