BDD can be a problem for family, friends and partners. It can be upsetting, confusing or infuriating that the person you care about persists in seeing themselves as ugly no matter what you tell them. You may have spent endless hours trying to reason with and reassure the sufferer, to no lasting effect. At a loss to know what to do or say, some family members end up providing funds for cosmetic procedures in a desperate hope that it will bring relief to their loved-one’s pain. Studies suggest that people with BDD are rarely satisfied by a cosmetic procedure and their symptoms of BDD frequently persist.

General guidelines for relatives

However odd your loved one’s behaviour may seem, it is just part of BDD. BDD is not a sign of madness – it’s simply a disorder, of the kind that can affect many people at some stage in their life. Remember BDD is not ‘bad’ behavior done to annoy you.

If you have a relative or partner with BDD, it’s still important to set consistent boundaries with behaviors that are unrelated to BDD, and to problem-solve BDD behavior where it impinges on your family life (e.g. the length of time the person spends in the bathroom when everyone is getting ready in the morning).

BDD is not something that can be easily stopped. It will take time, commitment, and the right guidance to improve everyone’s quality of life. Each person needs to overcome his or her problems at his or her own pace, even though this may be a lengthy process. As far as possible, stay patient and optimistic about recovery.

Avoid the blame game

No one should be blamed for BDD – it’s not the fault of the person who has it, and nor is it your fault as a relative. Hence there is no need to feel guilty for ‘causing’ BDD, even if there is a possible genetic link. If you start blaming your genes then you can go all the way back to our reptile ancestors!

Encourage your relative to seek help

Encourage your relative with BDD to seek professional help with therapy or medication if they need it. Support them in either or both routes, and do everything you can to help them change. This means:

helping them to understand and deﬁne their problems clearly

if they want you to, being an ally as described above

encouraging them to persist with their treatment

and praising improvement, however small.

Don’t participate in BDD

Families should not try to adapt their ways of doing things to accommodate a relative’s worries. Don’t put family life on hold. Accept that BDD may complicate family life, but get on with it anyway, and encourage your relative to maintain as normal a lifestyle as possible:

Try not to take on their responsibilities (unless of course you are a parent of a child).

Don’t make excuses for them (e.g. about their being late for work or for an appointment).

Don’t collaborate in trying to find ‘magic solutions’, such as getting details about cosmetic surgery out of the paper or offering to pay for surgery or provide a loan.

If necessary, compromise in the short term in the way we have described, but draw the line when new avoidance behaviors and safety behaviors start.

Avoid getting drawn into debates about the sufferer’s appearance, or providing reassurance. It is however important to provide emotional support.

If you have been participating in your relative’s BDD up to now, start to find ways of changing this:

If the person is in therapy, ask your relative if you can see the therapist with him or her and discuss a program of reducing your involvement in your relative’s BDD.

If the person is not in therapy, try to negotiate a program of gradual withdrawal from the person’s safety and avoidance behavior before you implement it.

Make sure that you communicate that you are changing your involvement in order to help rather than punish.

Practise saying ‘No’ or ‘No, thank you’ to requests for reassurance, checking, or debating.

Help your relative to see the downside of you participating in avoidance and safety behaviors and the effect on your relationship. Highlight how long the effect of the reassurance lasts for and what the effect is on their doubts.

Anticipate how you will deal with your relative becoming stressed or irritated by your new way of responding and have a plan that you can both agree upon if he or she becomes aggressive or angry. Where aggression is a problem, always ensure your own safety, if necessary by calling the police. You may have to be very persistent until requests for reassurance or rituals stop happening, because if you respond just once, it immediately becomes more likely that they will involve you again.

Remember:

Individuals with BDD will not come to any harm as a result of anxiety, though they may be distressed in the short term.

Accommodating rituals and avoidance means that you are helping to fuel BDD in the long term – and you are not taking care of yourself. It may feel as if you’re protecting yourself from stress and helping someone with BDD, but the effect is the opposite.

What is good for the family is good for the person with BDD, and this can only occur when no one else engages in the BDD. A family that is all pulling together can provide better support for your relative with BDD. Its members can also better support each other and solve problems more efficiently. Working as a team to overcome BDD is tough and usually best done with the guidance of a therapist.

Be a coach and cheerleader

You and your relative both need to see BDD, and not the individual experiencing it, as your shared enemy. Approach the problem as a team, working together. As your relative improves, see yourself as a coach shouting encouragement from the sidelines, or cheerleading, as you become less involved. Enthusiasm, empathy, understanding and general support are the best help you can provide.

Looking after yourself

Make sure that you communicate, both with your relative who has BDD and with everyone else in your family.

Remember that you may need help and support yourself.

Make sure that you continue to do things you enjoy and have people to talk to about your own feelings and concerns.

Eventually, you may decide that, for the sake of your own mental health, you can’t carry on caring for your relative with BDD. In that case you’ll need to communicate as a family and get help from the local services.

Feelings such as guilt, sadness or anger are normal in those caring for a relative with any long-term disability.

Try not to engage in self-pitying thoughts such as ‘Why me?’ or ‘Poor me, I don’t deserve to have BDD in the family.’ These will only make you feel worse and feed another vicious circle.

Try to detach yourself emotionally from your relative’s BDD and take it less personally.

If you’re not coping emotionally or it is affecting other areas of your life, seek help. There may be a local caregivers’ group or, even better, a group for caregivers of individuals with BDD. Alternatively, see your family doctor for a referral or go directly to a therapist.

One of the most important things that you can do to help someone with BDD is to remain calm, patient and optimistic that the problem can be overcome. BDD is a serious mental illness and the person suffering from it can no more ‘snap themselves out of it’ than any of us could if we had a physical illness. BDD needs treatment and steady rehabilitation. The most important role to play is of a supporter or cheerleader as the person takes steps upon the road to recovery. This might be as simple as showing interest in progress and celebrating success, or might involve going along to a social situation to help make it a little easier with some moral support.

It can also be helpful to try to focus upon ‘reaching’ and ‘connecting with’ the parts of the person that are not their BDD, talking about other interests, perhaps, and helping the person engage in activities and pursuits that used to be part of their life before BDD. Caring for someone with BDD can be very demanding, so it is important that you take time to care for yourself as well.

What if a relative refuses to seek help?

If your relative continues to refuse help and you decide that you cannot go on any longer with things the way they are, you will need to explore your own options, such as ﬁnding your relative independent living arrangements by getting help from your local mental health services.

Local mental health services do not always respond positively to requests for help for a relative with BDD who does not want help. The main priority for a psychiatrist in public health services is patients with ‘severe mental illness’, especially those who may be suicidal or a danger to the community.

UK and US mental health law allows a patient to be detained in hospital against their will in certain circumstances; but in the absence of a risk to themselves or self-neglect, patients with BDD are unlikely to be admitted to a hospital and would, in any case, be unlikely to benefit much from admission to the average acute psychiatric ward.

Short-term in-patient care in a national specialist unit where the staff are used to dealing with BDD patients and regular CBT is available, is more likely to be helpful. In others a trial of medication may be given against a person’s will and this might be helpful to some people.

Remember: recovery from BDD is a process

When your relative is recovering, you may expect everything to go back to how it used to be. However, this may not be how it happens at all, and the family may need to go through various stages of adjustment. This is normal. Each person will adjust and recover at a different rate. You may want to see BDD as something that is ‘over’ or ‘ﬁnished’, but remember that setbacks are part of the process.

In summary, BDD can have a profound effect on the person with BDD and on the person or people who look after them. However, though the situation may sometimes be difficult, it is never hopeless, and there is a lot that you can do as a team to help each other.