I’ve worked with half a dozen people over the last few years with the obsessional fear that they are too fat. One such person is Jen, a very pleasant young homemaker who is not considered overweight by anyone but herself. She is actually 5’ 5,’’ weights 130lbs, and in terrific shape, because she works out every day. Yet, Jen would look in a mirror, observe “a kind of funny looking bump like an little tumor” in the area of her belly, and have the thought, “Oh my God, look at that! I could never be attracted to anyone who looked that way. It’s just terrible. I’ve got to do something about it.”
“I spend a crazy amount of brain time on this,” Jen told me. “What if I just get fatter and fatter and my husband doesn’t want to have sex with me? What if because of that we can’t have any children? Then we’ll have to get a divorce….” On and on go the fears. In order to provide relief, Jen would review over and over in her mind her dietary plans, her work out schedule, how she would rededicate herself to losing weight, and how she would dress to cover her ugly feature. “I’m always scanning,” she said, “always looking at other girls to see if I’m attractive enough.” Jen had also become a true expert at sneakily coaxing reassuring words from her husband about her appearance. All her planning and all the behaviors addressing the “fat problem” were compulsions.
This sort of body-image problem is, strictly speaking, classified as “Body Dysmorphic Disorder.” For all practical purposes, it is a type of obsessive-compulsive disorder. What happens is that a normal concern (appearance) is evaluated improperly by the fear system of the brain. It is not dismissed as it should be after a reasonable amount of reflection. Soon compulsions develop, such as overanalysis, mirror checking, and reassurance seeking, which only serve to reinforce the fear.
Jen has made excellent progress in dealing with this fear. It continues to cause problems, but most days now she is free of trouble. She has worked hard at therapy, monitoring her symptoms, delaying and stopping compulsions, “sitting” with her obsessional fears, and practicing ERP exercises such as focusing on an unflattering photograph of her belly. I asked her what has been most helpful. Different people give different answers to this question, since any one of a number of different therapeutic strategies can work best. Here’s what worked for Jen. She articulates a couple of really good points.
I journal about the fat-thoughts every day, and that has been most helpful of all. I put down what the thoughts are, how they make me feel, and what I do to put down the anxiety. At first, I was scared to do it; but writing them down, just looking at them, helps me demystify the fear. Sometimes I’ll read them over and over to break them down so my rational side can see it. Now I think, “Okay, this is OCD. It’s okay to experience this. Let the fear in, rather than trying to fight it with a positive thought. It’s okay to sit in limbo, rather than trying to get a logical solution.” Typically after a bit of time the fear goes away, now. The whole key is recognition, because if I don’t recognize what it is, I’ll do a compulsion.
* note: all the names used in the blogs are made up, and the cases described are not specific to one person.