Take a generally anxious person and raise him/her in a complicated family and confidence-quashing peer/school environment. Immerse her in a media-driven, perfectionist and competitive culture. Ten years later, you might see someone like my client, Julie, out having dinner with friends. Each of a dozen times you glance over at her table, she is peering into a compact mirror, perhaps applying fresh lipstick, but more often observing and smoothing the lines around her eyes and mouth.

You might meet Beth, another client, at a party. Beth appears to have an itch or insect bite on her stomach as she frequently grabs at the skin above the button on her jeans. Several times each day, she disappears to a private space to perform a hundred repetitions of ab crunches, hoping to drain that final drop of fat from (what she refers to as) her “belly roll” (Note: as fitness and wellness professionals, we know that muscles do not use the fat stores immediately above them to fuel activity).

During my 20 years as a fitness professional, I have never attempted to diagnose and/or treat an individual with a psychological/psychiatric disorder, as doing so would be out of the scope of my practice. That said, the many years of frequent contact with hundreds of body and health-conscious people has presented me with opportunities to observe a wide variety of peculiar (yet not necessarily pathological) behaviors, idiosyncrasies, rituals and habits, including those described above. Would Julie and/or Beth meet the criteria for a diagnosis of body dysmorphic disorder (BDD)?

Diagnostic Criteria for BDD
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), is the latest version of the diagnostic manual of the American Psychiatric Association. Listed below are three essential criteria for a diagnosis of BDD.

  1. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
  2. The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
  3. The preoccupation is not better accounted for by another mental disorder (e.g., the dissatisfaction with the body shape and size in Anorexia Nervosa.)

Julie might tell you that her concern about her facial lines is not unusual, but simply a typical reaction to comparing her 28-year old skin to the pore-less, hairless, airbrushed illusions she sees on magazine covers. What about Beth? Others observe that she frequently pulls at her belly, but few (besides her therapist and I) know the frequency, the secrecy or the compulsive nature of her crunching bouts (or the distress/anxiety she experiences if unable to perform them). How debilitated are these women?

While Julie’s and Beth’s BDD behaviors seem excessive, perhaps shocking to some, the two women appear to be able to function in the world. While Julie talks about consulting a dermatologist to discuss dermal fillers, she has not yet done so. Beth admits to thinking about liposuction, but remains in the “pondering” stage. Perhaps neither woman meets the criteria for a full-blown diagnosis of BDD. But, how much time and distress would warrant one?

As discussed above, it is not within the scope of our practice to determine that. However, we have a responsibility to serve our clients and to plan fitness/wellness programs for the complete individual. As such, we need be aware of all of the physical and mental health issues that may effect a client’s participation in our programs. We also need be cognizant of how a client’s physical and mental health, limitations or issues impact exercise partners and other members of our exercise communities. For example, in a group exercise setting, a very fit-appearing person discussing liposuction would not go over well. (Yes, it has happened.)

How would I deal with an individual who exhibits BDD behaviors? I would approach him or her personally and privately and share my perceptions of specific behaviors that I have observed. I would ask if my perceptions seem valid, share my concerns, offer information, as well the name(s) of appropriate professionals or professional organizations that he/she could contact for help. I deal with a client who exhibits BDD behaviors the same way I deal with all clients from day one. I make approaching them with a concern a natural part of the ongoing relationship.

How to Help
There are many things you can do while staying within your scope of practice.

  • Learn about your clients (get acquainted).
  • Establish a good rapport; ask and invite questions.
  • Obtain a complete medical and exercise history, and list of personal goals.
  • Foster respect and faith in you as a fitness/wellness professional, but clearly establish the scope of your practice.
  • Assure them that you will refer them to other appropriate professionals when or if necessary.
  • Develop and maintain relationships with other health care organizations and allied health professionals as internists, cardiologists, orthopedic physicians, chiropractors, physical therapists, nutritionists, psychiatrists, psychologists, and pharmacists so that you can regularly contact them with general or specific questions or to refer a client.
  • Stay up-to-date on current research regarding exercise, nutrition, stress management and mental health.
  • Learn the signs and diagnostic criteria for BDD, Anorexia Nervosa, Bulimia, and other disorders.
  • Call or e-mail all clients on a listserve on a regular scheduled basis and encourage responses.
  • Regularly e-mail interesting tidbits of information to clients.
  • Plan weekly group or personal discussions with clients about interesting issues and topics; after discussion, invite comments and questions.

What’s so sad about BDD, and disorders like it, is that it takes up so much time and displaces so many life-affirming opportunities! Getting help is critical.

Marla Richmond, MS, is an exercise physiologist, health counselor, author and owner/operator of Together for Life, Inc. in Deerfield, Illinois.