Hi,

I know this forum is mainly about re-feeding, but I just wondered if anyone else her has had this situation.

As I`ve mentioned before my daughter has had AN for three years now, she`s spent a total of 12 months of that as an in-patient.

The past few months she has become obsessed with the shape of her nose. She says she thinks that`s why she keeps relapsing with the AN because her nose depresses her so much.

Now to me she has a perfectly normal nose, but it really is becoming a problem for her, she won`t go out and she sits with her hands over her face constantly. She has even self-harmed because she hates herself so much.

Her psychiatrist says it may be a way of diverting our attention away from the anorexia, or that she has just convinced herself that this is why she got anorexia in the first place. He says that even if something was done about it then she probably would move onto something else. 

My daughter is certainly not a vain person, so I don`t think it`s about her wanting to be perfect, I really believe that in her mind her nose is a problem to her. I really feel like looking into doing something about it just to take the anguish away from her even if it is part of her anorexia.

Does anyone else have someone with AN who became obsessed with something else, and if so what do you think I should do about it?

Regards Pam

I must confess, I was so upset yesterday when I read your suggestion, Trisha, that I was unable to respond.

Let me go on record to say that it is deeply offensive to me that anyone, especially a trusted authority figure, would even discuss plastic surgery in this situation.

The problem is not the nose, any more than an eating disorder is about a rational fear of obesity. You cannot talk someone out of a hallucination, nor should you offer comfort in the form of collusion with the illness.

Self esteem and body image are complex things, but they have zero to do with how you actually look. Engaging in debate with the sufferer about the actual appearance is fruitless, and potentially dangerous. The sufferer deserves comfort, support, listening, and good clinicians to work on the cognitions and often on the brain chemistry.

Not having seen the nose we are discussing, it is hard to say if the child has a valid concern or not. You'll notice that I only suggested consultation-not actual surgery. A reputable plastic surgeon will tell you and her that she's fine if she is. What about braces-do you think everyone should live with misaligned teeth or micrognathia because they were born that way? Supporting your child's natural appearance is of course very critical within reason, but if for instance a child is being tormented incessantly at school over a particular feature it's a lot easier for parents to tell them it looks fine than to get them to believe it. Sometimes an expert opinion is in order.  How about an orthodontist visit, since that's generally something that parent's feel fine about?  Even if she has already had braces, you can discuss her profile with the orthodontist (without her there, first, to be sure you want to share the discussion with her). Braces probably wouldn't be wise while she's still sick, but the doctor may have suggestions for treatment that can adjust her profile after she recovers.

                                                           Trisha

And the whole BMI thing is so flawed anyway-these one size fit all "healthy" weights look really low to me from my own personal experience. I'm five foot four and a half and quit having a period below 120, don't feel normal at all until I'm over 150. I like to stay about about 175-180 which looks obese on paper, but is IRL very little body fat with my muscle mass. Which I'm very proud of and took lots of cardiac rehab to build (<G>

http://www.msnbc.msn.com/id/14396741/wid/11915773?GT1=8404

If the BMI issue has been beaten to death here perviously as it has on so many other sites, please delete. Thanks!

Just adding about the BDD thing, it can exist apart from AN/starvation and could possibly trigger dieting depending upon what the body part concern centers on, and so lead into AN (rather than being a consequence of starvation). Of course, starvation seems to trigger these secondary distortions also.  

This is the chicken/egg problem I've had all along with my d's eating disorder and approach to treatment.  She did think her cheeks looked too full before she became eating disordered, but that component actually seemed mild compared to her other oc's with numbers/counting, scrupulosity/ritualizing to offset imagined bad happenings, time obsessions, and more (before AN).

My son (10) also has ocd, and currently thinks his arms look too big and his legs look too hairy (this is just one of his obsessions-others are not bodily related)  to degree that he absolutely refuses to wear short sleeves or shorts-this was in summer with PE and hot weather. He will soon resume ocd therapy ( halted during my d's crisis)  and I'll get some help, I hope, in getting him into short sleeves and shorts as "exposures".  I feel cautious with him b/c I do feel he is at risk for becoming eating disordered if control of appearance concerns becomes weight related-i.e things like arms being "too big" .To add the malnutrition on top of psychoneurological problems already there, I have learned, is disastrously hard to treat.

My oldest d (18) has dealt with bdd over her skin since 6th grade (so there never was any dieting/body image concern) and even developed agoraphobia. She has gotten better and more confident with therapy, part of which has been to  expose her skin without make-up, and with insignificant blemishes (like any teen may have) so on. This can be excruciatingly difficult at beginning though.

Suggesting any kind of laser or dermabrasion or plastic surgery ( regular dermatology and minimal facial regimen is ok) would run comptelely counter to recoginized treatment approaches, it would only reinforce the distortions. We also covered mirrors but eventually uncovering them may be a helpful exposure.

The confusion lies in the fact that "normal" people seek corrective surgery or treatments, BUT without undue severe anxiety prompting them. Seeking dermabrasion surgery etc when one is severely anxious to point of agoraphobic over the appearance concern is a different matter. "Fixing" the concern can become a chronic "fix" or addiction that can be extremely counterproductive. 

 I would agree that a fixation on one's nose could well be a form of BDD in someone predisposed genetically (anxious and perfectionsitic individual) and treatment would likely center upon exposures re her appearance, both real and imagined, and addressing cognitive distortions ( everyone is looking at my nose, no one has a nose like mine etc) all which could make her feel extra anxious and uncomfortable,  until the sense of  "disfigurement" fades away.

Not only can you not suggest corrective surgery to someone with BDD, you often cannot even reassure them that the nose or whatever looks fine, it will just become a trap of reassurance seeking that is only temporarily helpful. It might work better to say that many people have all different size noses and yet are well liked and attractive.

(For the record I have 3 kids without any ocd problems too, I don't know why the other 3 got unlucky, but there is alot of sub-clinical to more severe ocd in both sides of the family).