Complexity in obsessive-compulsive and body dysmorphic disorder – a functional approach to complex difficulties

Abstract

Abstract. Obsessive-compulsive disorder (OCD) and related disorders such as body dysmorphic disorder (BDD) can take many different forms of presentations. The term 'complex' is common and inconsistently used in both OCD and BDD. Practitioners often refer to complex OCD or BDD when patients present with severe co-morbid problems, often in the context of personality difficulties, dissociation, difficult early relationships and trauma; or when the illness is chronic and debilitating with previous multiple treatment failures. Current best-evidence treatment protocols for both disorders focus heavily on exposure and response prevention (E/RP) but with moderate success, particularly in patients who are deemed 'complex', and often those with relevant shame and/or disgust-based past experiences. The aim of the present paper is to (a) describe factors that contribute to complexity in OCD and BDD, and (b) link these with theory and practice. We emphasize the importance of understanding both the function of OCD and BDD-related behaviours (rather than the content of obsessions or compulsion), and the context in which they occur such as the family. We illustrate complexity in OCD and BDD using real case material, using a functional and contextual approach to formulate the client's difficulties, and demonstrate how E/RP can be enhanced successfully with imagery rescripting, family work, and compassionfocused therapy.

“If only he were blind”: Shame, trauma, and dissociation among women with body dysmorphic disorder in physically intimate relationships

“…NICE guidelines ( 2005 ) recommend that psychological assessment should cover interpersonal functioning at work and within friendships. In line with Sündermann and Veale ( 2017 ), this study highlights the importance of a full functional assessment of the interpersonal correlates, as well as the intrapersonal correlates, of BDD experience. This assessment could also include sensitive questioning about the impact of BDD on partner relationships and vice versa, and thus open a space for a potential exploration of the place of physical intimacy among the concerns, where this is felt to be relevant.…”

“…For example, Dyl et al ( 2006 ) found that among an adolescent psychiatric sample, participants with body shape or weight concerns had significantly greater symptoms of PTSD, dissociation, and sexual preoccupation or distress. Similarly, Sündermann and Veale ( 2017 ) suggest complex BDD in adults is associated with dissociative experience and trauma. Möllmann et al ( 2019 ) found that gazing at facial features increased dissociation among a non-clinical female sample, suggesting a self-perpetuating cycle of triggers of distress and attempts to cope with it.…”