Not happy with how we look: Negative body image & Body Dysmorphic Disorder

Can you imagine what is would be like to have your beautiful young son or daughter come to you with such hatred for their appearance that they are begging you to take them to a plastic surgeon?

I think from time to time we all check out our image in the mirror and make an evaluation of it.  Some people (young and old) make such critical evaluations of their appearance that they start to believe that they are unable to contribute to any sort of life because of their appearance.  When this becomes debilitating, we usually consider a diagnosis of Body Dysmorphic Disorder.

Our body image is different to an image of our body.  An image or photo of our body captures how it is at any point in time.  Our body image, though, is the representation we have of our own bodies.  It is essentially a judgement or series of judgements we make about how we think we appear.

When you ask people to tell you about their bodies, rather than give you facts , for example, on the colour of their hair or their measure height they usually give you judgemental words like plump, skinny, solid, pale….even ugly.  For most of us, this is not a problem, but for a few, the way their body image becomes central to their level of happiness.

When we determine our worth or happiness by our judgement of how we look, things can get pretty complex.

Body Dysmorphic Disorder or BDD is a diagnosis used when there is an intense preoccupation with a perceived flaw in physical appearance. (For most BDD it is with people’s own appearance, but BDD by proxy can mean that parents become obsessed about flaws in their children’s appearance).  Individuals with BDD often spend lots of time checking and worrying about a particular aspect of their appearance. They may spend a lot of time comparing their appearance with others, and engaging in behaviours designed to try to hide or conceal the area of concern or generally try to avoid being seen by others.

It is thought that BDD affects 1-2 percent of the population and it does not seem to vary with gender.

In the clients I have seen with Body Dysmorphic Disorder, they usually focus on one feature in particular – their teeth or the shape of their lips and sadly, if they do take steps to have these adjusted to their liking (people with BDD are often frequent customers of plastic surgeons), it does not always mean that their happiness improves and they will then go onto to target the next part of their body that they find the most displeasing.

The thinking if ultimately something like “if I can just change the way I look, my life will be wonderful”

BDD is  much more than just vanity or being dissatisfied with how they look, it can become obsessive and often co-morbid (or exists together with) with depression, anxiety (especially social anxiety) and I have seen it accompanied by self harm and suicidal ideas, too.  It can make it hard for a young person to leave the house, go to school or uni, or meet up with friends…or if they do, there needs to be much time trying to cover or adjust a certain aspect of their appearance.

This means BDD can interfere with living with others.  Those with BDD will often continually seek reassurance about their appearance or spend lengthy times in the family bathroom or be frequently late for work or school. There is often quite a deal of secrecy and shame associated with BDD and BDD can quite often be associated with financial difficulties, too, with money being spent on treatments or cover ups.

Oversimplifying it, but in an attempt to explain how BDD starts and is maintained we could consider it  going something like this example (although imagine it being much more complex/less staright forward):

  • Someone tells me I have a crocked nose
  • I believe that I have to look perfect to be liked by others
  • I spend hours trying to cover up my crooked nose with makeup, but that all gets too hard and the products I use have cause swelling and redness, so I start avoiding going out whether others will see me crooked nose. I keep checking with the people I love about my nose, but that doesn’t satisfy me for long.
  • I stop socialising, friendships drop away and I never get to test the idea that I have to look perfect for others to like me or want to be friends with me.

Where does BDD come from?

It is thought that most BDD starts in adolescence and that much goes untreated for many years.  Adolescence is a time of many body changes, and also for some, an increased risk for acne, but other times of life where the body changes can also be triggers – like the emergence of wrinkles or loss of hair with aging or new scarring after an accident or medical issue.

Those at risk of BDD or serious negative body image have often been teased or excluded and are also more likely to associate with peers or even family members who are very focused on appearance. Certain personality types may be more prone but also, social and cultural pressures are thought to contribute including social media. I have also seen BDD that began following a period of childhood and family trauma.

There are so many industries that depend on us being dissatisfied with our body image – Industries worth billions of dollars.  They flood the media with direct and indirect messages about happiness being derived from appearance.

How can we prevent it?

Sadly, at this stage, we don’t’ have any strategies that definitely prevent BDD.  I like to try to educate children about the powers of advertising and the tricks marketers pay to make us buy things.  However, the best the research can suggest is that people seek treatment early.

So, if you are a parent of a teen, it is usual for them to spend more time in the bathroom and in front of the mirror as they approach puberty, but if the checking is accompanied by frequent negative statements about their appearance, constant comparisons of themselves to others, regularly needing reassurance that they look okay, and avoiding socialising or leaving the house, you  should increase your level of concern.

The first point of call should be your GP or Mental Health professional.  A proper diagnosis is essential.BDD has some similarities to Eating Disorders in that it is also about body image, but the preoccupation is usually different, with eating disorders normally being about weight and shape and usually leads to a change of eating patterns.

Treatment can include medication and psychological intervention.  Psychological treatment is focused on tackling negative body image by building body acceptance and using techniques to help reduce the amount of time spent obsessing, checking or seeking reassurance about appearance.  Psychologists can also help with uncovering and challenging assumptions and negative predictions that link appearance with ideas of success and happiness.  Psychologists can also help a person to tackle their avoidance or behaviours that set up self fulfilling loops around unhelpful assumptions

There is some very useful information at the BDD Foundation website.

If you have young children (preschool and early primary) and you are concerned about them developing a negative self image, perhaps you could share “You are Like You” with them to open up some conversations about their thoughts about themselves.


A good night’s sleep

“Get back into your bed and go to sleep!”

“But I just need a glass of water!”

Sleep – we all need it.  It’s a time when our body does important rest and restorative work and our brains take time to process information.  Sleep has a big role to play in our physical and mental health.  Troubled sleep can be linked to the well being of a child or others in the family and poor sleep can also indicate other mental health problems for the child.

As an infant grows, normally their sleep patterns will settle or become more consolidated. That is, instead of getting their sleep in a series of naps,  sleeping hours and waking hours become longer.  Sleep patterns change as a child grows – at first, most often during the first  6 months – bubs will have 6 to 8 sleeps in a 24 hour period and as they grow, they start to consolidate or join  up these sleeps – hopefully with more at night and less during the day.

There is variation in how much sleep we need, but for adults generally it’s 8 hours, primary school 9-11 hours and preschoolers around  11 to 14 hours.  Newborns usually sleep 14-17 hours, but not all in one go.

Two main things determine how sleepy we get.

  • Thing 1 – sleep will depend on how long it has been since we last slept and
  • Thing 2 – circadian rhythms – our internal body clocks mean we get sleepy at certain times of the day regardless of when we last slept

We can measure sleep in different ways.  We can have people report subjectively on their sleep by, for example, keeping a sleep diary, or we can use machines like polysomnographs. In fact, studies using high tech equipment indicate that the EEG activity in different parts of the brain, front versus back or left versus right, appear to reflect different ways that the brain organises itself as a child grows.

It is thought that sleep has strong links to the way brains process information and poor sleep or not enough sleep can affect thought patters, emotion and behaviour.

Sleep problems vary, too.  People can have troubles getting to sleep (called sleep onset problems) and these can start in preschool and last well into adolescence and adulthood.  People can experience insomnia (trouble getting to seep or staying asleep), sleep-related breathing issues (sleep apnoea, tonsillitis), hypersomnolence or too much sleep (narcolepsy), circadian rhythm issues, parasomnias (sleep terrors),  and sleep related movement disorders (restless leg syndrome).

Sleep problems can originate from a number of casual factors and that is why it is important to get a proper assessment if sleep is becoming a big problem for a young person.

Sleep problems can be caused by:

  • being uncomfortable or environmental issues
  • pain or illness
  • neurodevelopmental disabilities like autism, certain syndromes like Rett or Tourette’s syndromes and intellectual disabilities
  • medications and stimulants such as caffeine
  • certain mental health issues – depression, anxiety, conduct disorders, ADHD or trauma
  • parent mental health, parent stress and parenting skills

Sleep issues are linked to mental health disorders in a “chicken and egg” way.  Some sleep issues are a symptom of mental illness and other sleep issues may contribute to the development of a mental health concern.  When it comes to mental health, we definitely shouldn’t ignore someone’s sleep issues and it’s important that clinicians take the time to ask people about their sleep.

Before we get into what helps, it’s important to think about what does not help. The plethora of information and opinions available to parents is overwhelming and one of the areas that people love to share opinions about is children and sleep. Remember before about the age of six months, it is very likely that a bub will wake in the night and that this is what most babies do.  Over time, they should start to condense the times that they sleep having fewer sleeps during the day and more, longer sleeps at night.

Warning –  If you are having a sleepless night with your young one, don’t go surfing the net…especially when you, yourself, are sleep deprived.  You may drown in a sea of opposing advice about how to settle an infant.  Should you co-sleep?  Should you feed in the middle of the night?  Should your young one be in bed by a certain time?

There are plenty of people who will give you an opinion.  You need to choose something that is inline with your parenting values and you need to weigh up the pros and cons of your child, their needs, your health and family functioning and your ideal values before deciding how you might proceed.  I know a lot of families choose very attachment focused parenting options sometimes and these will usually include co-sleeping and are lovely if families have the time, determination, energy, health and support to manage the impact of co-sleeping.  However, if a lack of sleep or disturbed sleep is impacting on your child’s happiness and wellness, your day to day life, or your relationships with important other people, then it’s worth getting some help and prioritising what is important to you.

The things that can help with sleep problems will vary depending on the nature of the problem, but might include:

  • routines and methods to settle young ones . Generally speaking, routines help our brains to predict what is coming next and this can help to calm us.  However, the things that calm each of us can differ – a lot!  One of the earliest tasks of parenting is to work out what will soothe your baby and what upsets them.  There are differences, even with babies from the exact same parents – How you swaddle them , when you bath them, when you use more vigorous play and rocking, how much they like to be held and touched and by whom.
  • avoid caffeine and stimulants (including computer or light exposure –  the light from computer screens and tablets can be quite stimulating)
  • try to have a regular bedtime and make night time boring – not too much active play on the way to bed!
  • try to have children use their beds just for sleeping. Bed needs to be comfy, not fancy.
  • consider light and dark exposure. Make it clear that there is a day time/night time difference in the amount of light in the room where you want the child to sleep
  • behavioural treatments can help with bonuses for bedtime routines, staying in your own bed all night, for tantrums around bedtime and also gradual exposure for removing an adult from the room when the child is going to sleep
  • assistance with nightmares and dreams – helping kids get back to sleep after a nightmare is on of my favourite things to do.  I like to help them with a little bit of education about the brain and dreams, some grounding exercises and lots of happy imaginings.
  • medication or surgery. Where it is medically indicated, some people sleep better with medication and your GP or paediatrician will be best to guide you.  If a little one’s sleep is regularly disturbed by breathing or illness issues, surgery to remove tonsils and adenoids might also help.

So, generally, if a little one is having trouble getting to sleep, there are a range of factors that could be causing the issue – medical, behavioural, environmental or familial.  The best treatment will depend on tackling the likely causes and your family doctor, paediatrician, or maternal child health nurse will be able to help you unravel the possible reasons.  A Psychologist can help with some of the behavioural aspects of getting to sleep and also any mental health concerns that might be contributing.  Overall, sleep issues are well worth investigating and treating.  A good night’s sleep can help us manage many of life’s day to day hassles and enjoy life’s day to day delights.

For more, especially on adult sleep, the National Sleep Foundation ( has some excellent information.

Procrastination- helping young people “get on with it”

“I’ll do it later.”  “I’ll start tomorrow.” “I’m waiting until I’m in the right mood.” “I work better under pressure.”  “I’m waiting for the rest of my group to get started.”

We all put things off from time to time or find it hard to make a decision.  For the most part, we can usually come up with the goods in time to avoid dire consequences.  However, some young people get so stuck in putting things off that it starts to have a big impact on their life.

Some people might procrastinate about health checks, career choices, finances, chores, and relationship issues,  but the type of procrastination that we know the most about is academic procrastination. Because the majority of research is done in universities, it’s much easier for researchers there to utilize the students in their courses when they study (we know a lot about the psychology of first year under-graduate psychology students).

We do know that chronic procrastination is difficult to change and, like most things in psychology, procrastination is complex.

Some people procrastinate a little bit and some people do it a lot.  Some do it to the extent that their lives, and perhaps the lives of others they care about, start to be affected.   Those students who procrastinate regularly risk poorer academic performance, including withdrawing from courses or failing to complete requirements.

In an attempt to untangle the complexity of academic procrastination, one of the things that researchers  have found is that there is a link between academic procrastination and certain personality traits.  Procrastination is associated with certain personality types; with certain levels of motivation; with stress, anxiety and mental health; and then it can still vary from situation to situation.

Generally, students are less likely to procrastinate if they are conscientious. Conscientiousness is about having a desire to do well and to be careful and vigilant. However, even the most conscientious student might procrastinate if they are frozen by anxiety or stress in a situation where, for example, they really want to please someone.  Procrastination is also affected by how close the deadlines might be and the size of the reward people are working towards.

Some people procrastinate because they are worried and some procrastinate because they are not worried enough!

Further clues to what might be going on for a procrastinator can be found in the students’ typical pattern and mood as well as their excuses, rationalisations or justifications.

Some people procrastinate because of perfectionism or fear of failure.  These anxious people form only a small proportion of the overall group of procrastinators, but usually they are the clearest to define or to see what might be maintaining their delays or indecision. Anxious procrastinators become confused, uncertain or fearful.  These students usually need help that targets their fears and worries to help them get unstuck.

However, the most common procrastinators are those with a high need to socialise and preference for a lot of variety in their life – the students who have a desire to try a big variety of things or who find it hard to tolerate boredom.  Some cite social reasons for procrastination.  Some are easily swayed by friends or offers to socialise.  Others procrastinate as a means of being a little bit antisocial or rebellious.  Still others procrastinate because they’re discontent with studies or have lost interest in, or energy for, the overall goal.

If you are a parent, teacher or an educational counsellor, you may well be keen to know the best way to assist a student who might be delaying work to the point where you can see it is starting to have a negative effect on their work and/or their mood.

Assisting someone to overcome procrastination is not a one size fits all approach because of the complexities involved.

It’s important to consider the various factors affecting the student at any given point in time and listen closely to their excuses and justifications to help guide you to assist them.

Not all procrastination needs treatment for anxiety, but those prone to anxiety, perfection and fear of failure may need some help from a mental health practitioner. If your child is prone to perfectionism or fear of letting other people down, try to help them celebrate and learn from mistakes, to ask for help and to broaden their interests to things that they may not be so good at.  See my previous blog.

Sometimes, there may be a need to improve conscientiousness by working on impulsiveness and self discipline.  At times, we need to help children learn to regulate their behaviour.  There are a number of in-school programs being adopted in Australia such as RULER  or Positive Education.  It will take researchers some years to work out whether these programs assist to reduce academic procrastination, but it makes sense to work on learning how to label and understand your emotions and learn to adjust them for different environments.

Those who cite social distracters may need some help with assertion or learning to say “no” to persistent social offers (see my blog about teaching children assertion)  or use available software to help them manage their social media use.

If “energy’ is an issue, perhaps have a student reflect on their own patterns of energy.  Are they a morning person or does their brain come alive at night?  Also remind them about exercise and eating well.

For some, it can help to look at their goals and rewards.  Break big jobs down into smaller ones but also make sure that the jobs are chained together for one big endpoint or reward – set smaller sub-goals, but don’t lose sight of the big one.

Overall, if you notice a student in your household or classroom is procrastination, don’t put off bringing it to their attention and asking if they would like some help with it.  Asking early and providing the right support early may prevent academic failure or withdrawal.

Assertion: Helping young ones manage difficult people

There are few certain things in life.  Sadly, like head lice in schools, there will likely always be difficult people that cross paths with your child from time to time.  And just like head lice, it’s wise to check in with your kids from time to time to see whether they are dealing with someone they are finding difficult and to help them with a plan to manage.

Now, when I say check in with your child, you would know by now that I don’t mean putting them through the third degree.  Most, but not all children will tell you if things are difficult with someone at school.  If you have noticed a change in your child’s mood after school that’s lingering over a number of days, it’s wise to check in with them directly.

Standing up for yourself and asking, respectfully, for what you need are important skills to learn – to learn to listen and understand others and to assert yourself.  Assertion skills are handy throughout our total life span, but of course we need to make sure we teach respect for ourselves and others in age-appropriate ways.

If your child complains of a bossy friend, it can be handy to talk about the assertion spectrum and balance in interpersonal relationships– although I don’t call it that with kids.  I tend to refer to it as the “Cool, Wussy and Aggro Seesaw” thing.

If we are aiming for a balanced and respectful relationship, we need to understand aggressive, assertive and passive behaviour…..Introducing Aggro, Cool and Wussy.

Little Aggro person is always angry and bossy and other people tend to feel a bit bossed round when they play.  If friendship is like a seesaw, then Aggro definitely gets the seesaw off balance.  Aggro is the one who likes to make other people feel sad (because it makes Aggro feel better).  Little Wussy person is the one who is sad to be around, tends to put themselves down, complains or whinges, is not very confident and looks lonely.  On the Friendship Seesaw, Wussy people usually put themselves in the down position, making it easy for other people (especially Aggro ones) to pick on them – not that anyone should pick on anyone…but if you want to avoid being put down, you need to make sure you’re not repeatedly looking or behaving like a Wussy.

Then there’s Little Cool Person.  Little Cool person is the ultimate in keeping the friendship seesaw balanced.  Little Cool person looks happy and takes care not to put others down.  Little Cool takes turns, shares, listens and speaks up. If Little Cool has a problem, Little Cool speaks up in a clear voice and asks for help (not whinges).  If Little Cool starts to feel a bit Wussy or Aggro, Little Cool will work out ways to make him or herself feel better – have some quiet time, do a drawing, go for a run, find someone else to play with.   In sessions, we might make some puppets or paper-plate masks and model Cool, Wussy and Aggro options for different problems.

With the Cool, Wussy, Aggro thing and the Friendship Seesaw, kids can start to think about their own behaviour as well as that of others when things start to get difficult.

As teens, interpersonal difficulties become much more strongly felt.  Teens can, for the most part, more easily take the other person’s perspective and understand some of the factors that can be making that perfect difficult to be around or to spend time with.  With assertion, teens can also begin to understand that alongside assertive, passive and aggressive positions, comes the passive aggressive position that leaves others feeling manipulated and confused.

It’s especially important that teens learn to communicate with others respectfully and can ask for their needs to be met without needing to rely on manipulating others or having others guess what it is they want or need.  Kids need to learn about how to say what they want or feel without blaming others.  They also need to know the importance of speaking up about things that are bothering them rather than leaving their needs and wishes unexpressed.  Helping them to use assertive “I statements” can assist.  Using “I statements” the emphasis is on saying what “I feel”, in what circumstances (“when”), and what “I would like”.  “I feel concerned when young people can’t ask directly for what they need and I would like adults to help them to communicate respectfully and comfortably”.  Assertive communication takes some practice and, as always, is helped by some good modeling from the important people around our young ones.

The way we manage difficult people in our life has significant impacts on our happiness and stress levels.  The inability to solve interpersonal problems without causing distress to oneself or others is characteristic of some serious adult mental health concerns.  The ability to solve interpersonal problems can prevent much life angst.

Interpersonal difficulties are a great time to have children start to look at their own behaviour as well as the behaviour of others. With the Cool, Wussy, Aggro thing and the Friendship Seesaw, kids can start to think about their own behaviour as well as that of others when things start to get difficult.