Episode 211 Transcript

You're listening to the Fierce Fatty Podcast, episode 211. Is it body image shame, body dysmorphic disorder, or anti-fat bias? I'm your host, Vinny Welsby. We pronounce them. Let's do it.

Hello. Welcome to this episode. Trigger warning about things we're talking about today: eating disorders, and we've got a brief mention of suicide rates. If that's not feeling good for you today, then skip this episode. We've got lots of BDDs, not on eating disorders. I guess it's a brief mention of eating disorders existing. Not as much as I thought. Anyway, we've got about 55 billion links for sources for today. I think it's almost always we have 55 billion links. I don't know if that's mega annoying or what. Anyway, you can go and find them in the show notes, which is fiercefatty.com/211. So, fiercefatty.com/211.

Did you know that the podcast episodes have transcripts? If you're a transcript person, then go to that same page, 211, and you'll see a link for the transcript. There were a few episodes where I wasn't able to do a transcript because I didn't have the budget for the transcript software. But now I'm able to have transcripts, and I have for a while. I just forgot to tell you.

With that in mind, if you would like to support the show so I can keep offering transcripts and keep doing episodes, then feel free to buy me a coffee on Ko-fi.com. If you just search fiercefatty.com/211 and Ko-fi.com, you'll see a thing there to donate, or there'll be a link somewhere. I don't know, scroll down somewhere. A link will pop into your head. If you're able to do that, fantastic. If not, then thanks for being here. I appreciate it.

So, the reason why I want to talk about this is that, in case you don't know, I'm now in my second year of doing a master's of counseling, aka psychotherapy. And we did a course on pharmacology and different diagnoses, and I wrote, I did a literature review on body dysmorphic disorder, just because it's a part of what I'm interested in.

And I thought that you might appreciate the comparison between body image shame or body shame, body dysmorphic disorder, and anti-fat bias. Like, are they the same? Does one influence others? Are they a part of each other in any way or not? Because these are questions that I've had. And I know that there are people who are saying, oh, that they have BDD. And what does that actually mean?

And you may be thinking, if you're struggling with thoughts about your own body image and you're really struggling, considering, like, maybe you have BDD or maybe you don't. Maybe you're just responding naturally to anti-fatness in our society. Or maybe it is BDD. Who knows?

It's really hard for me to not want to sing, "BDD got that big pussy energy." Do you know that from that shit, Girls5eva? That's such a funny show. Girls5eva. And it's, they've got a big pussy energy, BPE. And so whenever I hear BDD, I want to sing BPE, or borderline personality disorder. Borderline BPD, BPD got that borderline personality. Yeah, yeah, yeah.

Anyway, I shouldn't be singing that because it's about pussies. Well, I don't know, maybe if I'm talking to clients about it, they might like it when I'm an eventual therapist.

Anyway, so what is BDD? I'm just going to call it BDD from now on instead of saying body dysmorphic disorder.

So, a lot of mental health professionals will refer to the DSM. The DSM is kind of like this big book. It stands for Diagnostic and Statistical Manual of Mental Disorders, and it's like this big book of all of the different mental health conditions that we currently recognize.

There's a lot of criticism about the DSM because it's really white. It's sometimes, a lot of times, pathologizes things which don't necessarily need to be pathologized. It is sometimes, there's lots of ways that can cause harm. But this is the criteria according to the DSM for BDD.

Okay, so A: preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.

By the way, I'm going to be talking about these points later on, but I'm just going to be describing BDD first. Okay, so put a pin in your brain if you hear something and you're like, "Huh, what about that, Vinny?" Because already in that first sentence, I'm like, "Ah-ha."

So, B: at some point during the course of the disorder, the individual has performed repetitive behaviors, e.g., mirror checking, excessive grooming, skin picking, reassurance seeking, or mental acts. I'm going to tell you what mental acts are a little bit more in a sec. Comparing his or her, or their, I'm adding in, appearance with that of others in response to appearance concerns.

C: the preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

And D: the appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Okay, so basically, in BDD, individuals are preoccupied with perceived physical flaws, and the preoccupation must be associated with repetitive behaviors.

I said I'll tell you what mental acts are. So, repetitive behaviors can be physical and can be mental acts or cognitive patterns.

So, physical behaviors, like they mentioned there, are things like inspecting your reflection or camouflaging the quote, "problem area," or excessive grooming, skin picking, cosmetic interventions, photo taking and editing, changing clothes and compulsive shopping, excessive tanning, exercising, or weight lifting.

So, they're types of behaviors, and the list can be really long with different types of things that people could do.

And mental acts, so mental acts are internal cognitive compulsions that a person performs. And so, mental acts and cognitive patterns, so cognitive thinking, so compulsions and the way that someone is thinking.

So, these include things like comparing appearances. So, it could be silently or just noticing appearances of themselves and others.

Mental reviewing, so replaying past social interactions or memories to analyze how you looked, whether people were staring, whether the floor was exposed.

Internal reassurance seeking, so silently repeating phrases, asking oneself internally if you look normal or okay, or trying to logically convince yourself that the flaw is not that bad. So, you're almost doing like this coaching. You're trying to coach yourself internally.

Measuring or tracking mentally, and so looking at, like, the symmetry of your body, of your size or a certain body part without touching it or using a mirror. So, you just be thinking about your body.

Ideas of reference. So, this is strongly believing or fearing that other people are taking notice of them in a negative way and judging them and mocking them because of this perceived flaw.

Intrusive ruminations, and so this is like a real key part of BDD, is this persistent, ruminating, intrusive thoughts that are really difficult to resist or control, and it takes up many hours of mental focus a day. And then the list can go on.

So, that's what kind of the mental, that's like kind of what's going on in your head, and then also in this doing this stuff in your body is that the physical ones.

And so, lastly, for it to be BDD, it cannot be better explained by an eating disorder. So, it, for example, cannot solely be related to weight, like for someone who's diagnosed with anorexia.

Some stats on BDD. The prevalence in the US is between 1.7% to 2.4%. The average age that people, the age of onset, is 16 years old.

And gender, surprise, surprise, all of the stuff that I do, like looking at studies and stuff, it gets on my tits so much that they don't even consider that genderqueer people exist. There's not even the mention of it, just like in the diagnosis reading out saying his or her, like they've not even considered that there is a they or anyone else apart from men and women.

It really grinds my ears and gets on my flaps.

So, with that in mind, there's not a lot of reliable data around BDD and genderqueer, gender-nonconforming, non-binary people. Specifically BDD. But there is data showing that genderqueer people have higher rates of body dissatisfaction.

So, body dissatisfaction is different from BDD. Body dissatisfaction is like body shame, whereas BDD is a diagnosis.

The information that we have about men and women is that the prevalence rates of BDD are pretty much the same for men and women. However, the areas of concern are different. So, what the person is focused on.

So, BDD is very much focusing on one or more small areas, like your nose, like the shape of your thighs, like your hair. So, it's kind of more specific versus general, your whole body.

And so, for women, they are more likely to be concerned with skin, breasts, thighs, and body hair.

Women are more likely to be concerned with genitals, balding, and being muscly. And there's a subset of BDD called muscle dysmorphia, where being focused on if they're muscly enough.

So, people with BDD spend about three to eight hours daily obsessing over the flaws. So, it's a lot, and this causes severe emotional distress, anxiety, shame, sadness, and significantly impairs daily functioning across all aspects of life.

A lot of times, like, is something, do I have an eating disorder or do I have disordered eating? And a lot of times, with a lot of things, am I sad or am I clinically depressed? A lot of times, what the difference is, is the impact that it's having on your life. That's not the only difference because there's other things we'll explain in a second.

How much is this impacting your life?

And having body image struggles, body image shame, can be so impactful, really, really, really. And so, I don't want to diminish the pain that comes from struggling with body image.

But thinking about someone who has BDD, three to eight hours focusing on one area of their body or a couple, if they've got a few things that they're focusing on. It doesn't have to be just one.

So, three to eight hours a day doing these mental acts, those cognitive things, and those physical things, that would mean that you might not be able to leave the house. You might not be able to go to school, go to work, have relationships. It could mean that your whole life is engaging in this obsession.

The other thing that the diagnosis has is something called insight specifiers. And so, if someone is diagnosed with having BDD, they'll also have a diagnosis with how much insight do they have.

Insight means, do they know that what they believe about their body is incorrect?

So, say, for example, someone feels like their nose is too big. And by the way, I'm going to be talking about this in a second, okay? So, putting a pin about this.

Someone says their nose is too big, but the clinician is saying, "I look at your nose and I see that it's an average-sized or small nose," right? And so, does the person who has the feelings about their nose, that it's being too big, do they know that it's maybe what they would say is delusional? Or are they sure that their nose is too big, so they don't have insight about what's happening?

And so, insight could be good or fair, and that means recognizing that their beliefs about their nose or whatever it is are not actually true, but there's something in their brain telling them they're true.

Or it goes down to poor/absent, delusional. And so, that's the complete conviction that the perceived flaw is real and horrifying and terrible and needs to be fixed.

So, the causes of BDD, it's complex. It's biopsychosocial. You might have heard this before. In case you've not, biopsychosocial is to say that it's biological, psychological, and social aspects. It recognizes that it's not just one thing that's causing an issue. It's a group of things, right?

And so, BDD is biopsychosocial, and so genetic factors. Twin studies have shown that the heritability, that means chances that you're going to get it from your parents, of BDD symptoms is 37 to 49%, right? So, it could be running in families.

The other thing, so that's that bio. The psycho is interpersonal trauma. So, interpersonal trauma is strongly linked to, so BDD is strongly linked to adverse childhood experiences.

So, adverse childhood experience is also known as ACEs. And so, if you're curious about how fucked up your childhood was, you can go and check out your ACE score.

By the way, if you look at your ACE score and you're like, "Holy shit, this number is bigger or smaller than what I thought," and look at what happens if someone has a high ACE score and think, "Well, that's it, my life is fucked," that's not what it necessarily means.

It means it's a population level. People who've experienced abuse can have poorer outcomes with their health and with life, which makes sense, right?

In regards to if someone has had adverse childhood experiences, they could also be poor, racialized, not have access to education, in a location that's not safe, not have access to healthcare, right?

So it's a really complex issue. And so if you do look at your ACE score, don't think, "My life is fucked and I'm about to die," okay? You can just use it as a bit of maybe affirming data, if you like.

I think my ACE score is like, I've got... I can't remember what it was. I think it's about out of nine, isn't it? And I'm thinking I'm eight out of nine. I remember being like, "Oh my God, wow, I had a really fucking shit childhood."

Yeah, so anyway, so a high ACE score, which is trauma, right? And also higher rates of childhood abuse, neglect, teasing, and peer bullying.

And then socio-cultural influences, this is beauty ideals, social media, body comparison culture. And so those things, all these beauty ideals, that increases perfectionism, appearance dissatisfaction, and distorted self-perception.

Plus, under the socio-cultural influences, anti-fat attitudes that interacts with BDD and muscle dysmorphia, as well as other systems of oppression. So, for example, anti-blackness, that would be a good one with thinking about someone thinking their nose is too big. And so where is this idea coming from that a nose needs to be a certain size? And that will be coming from beauty ideals, which is based in anti-blackness, saying wider noses are unattractive because they are too black, right?

And so something like anti-blackness could be influencing a certain part, anti-fatness could be influencing something else. Like if someone's focused on their stomach and they say, "My stomach's too fat, my arms are too fat," that could be influenced by anti-fatness.

So people with BDD, they have a much higher suicide risk, up to 80% reporting lifetime suicide ideation, up to 28% attempting suicide. People with BDD, approximately four times more likely to experience suicide ideation compared to people who don't have it.

Comorbidities, so comorbidities is co-occurring conditions. And so, for example, if you have asthma, you might also have eczema. They kind of tie together, right? I think they're both autoimmune. This is me, I have asthma and eczema.

And so things that are occurring, they might not necessarily be related, right? They'd just be random, but anyway, things that people with BDD often also have is major depressive disorder. Up to 83% of people with BDD have major depressive disorder, as well as higher rates of social anxiety disorder, OCD, eating disorders, and substance use disorders.

So there's some stats. Do you know what I find really interesting and also heartbreaking about BDD is that cosmetic interventions are not effective at treating BDD. And a lot of people with BDD seek out cosmetic interventions, including surgeries. And often these cosmetic interventions leaves the BDD unchanged or worse.

And the reason is that the problem in BDD isn't necessarily the physical feature itself, right? It's the person's relationship to and preoccupation with and understanding their cognition around that feature.

So, for example, if someone has a nose job, they may then find a new flaw on their nose to fixate on. They may decide that the surgery didn't fix the original flaw. So they could say, "I have a bump on my nose and the bump is removed," but then the person could say, "No, there's still a bump."

And they could then also shift to a different, say within the nose, they could say, "Oh, but I've noticed that one nostril is bigger than the other." And probably, maybe it is because our nostrils, are they going to be perfectly symmetrical? Probably not. So they might then say, "Oh, the nostrils are bad. Now I need to have another nose job to fix this issue," right?

So fixing, I'm using in quotation marks, the issue is not going to fix very, very likely, is not going to fix the real issue because the real issue is in the brain, not in the body.

So, okay, so then body shame versus BDD. Body image shame is a quote from the Mental Health Foundation: "Body image shame is a painful emotional state where a person feels deeply inadequate, defective, or fundamentally wrong because they believe their body fails to meet personal or societal standards."

So you can have body shame and not have BDD, but body shame is very often, not always, a part of BDD. But BDD isn't just really bad body shame, right? There's lots of similarities between body shame and BDD and lots of differences too. I'm going to list some out.

The key difference is that BDD is a formal psychiatric diagnosis, and it's classified under obsessive, compulsive, and related disorders. So similar to OCD, now people say, "I'm so OCD," and there's different ways that that can manifest. And so it's under the umbrella of obsessive, compulsive disorders because they're spending all of that time and energy thinking and acting upon this perceived flaw, right?

Body shame isn't a diagnosis. Doesn't mean it can't be incredibly painful. And body shame is most strongly linked to how severe someone's distorted appearance beliefs are when they have BDD. So if someone has body shame and they have BDD, which is really common that both are going on, their severity of their distortion about their appearance is increased.

And then we also have general shame, so not just, "My body is bad," but "I'm a bad person." So if someone also is like, "I'm a piece of shit person," that is the primary driver for adverse outcomes. So that's things like depression, suicide risk, not being able to do things in their life, right?

Shame. Oh, my God, fuck shame. Honestly, shame. I think about shame all the time. It's just such a driving force in so much of everything that we do and we think, right, of, "Am I a good enough person? Do people like me? Am I lovable? Am I okay?" To avoid that sense of shame because it's such an uncomfortable feeling.

Okay. Body image shame versus BDD. So, many people experience body image shame, so up to about 75% of the population experience body dissatisfaction. And the vast majority do not meet the diagnostic criteria for BDD, whereas BDD, as we mentioned before, 1.7 to 2.9% of the population. So it's much lower. So 75% versus 1 to 3% ish. And I mean, like, the 75% with the body dissatisfaction is fucked up.

And with body image shame, the primary experience is feeling inadequate, self-criticism, and urge to hide or avoid social situations. Just feeling of, "I feel shit." And you may engage in a lot of the same behaviors as someone with BDD, but maybe not to the same extent.

Here's a quote from Eating Disorder and OCD Therapy, San Diego. So this is from a therapist. "When I work with someone experiencing body image distress, their discomfort tends to center on overall body shape and size. They often have some awareness of where those feelings come from, whether it's a critical parent, a culture that equates thinness with worth, or a lifetime of messages that their body is a problem to be solved. The thoughts, though very distressing, are often more redirectable."

Let me say that again. The thoughts, though very distressing, are often more redirectable. Exploring the systems behind the suffering can be genuinely therapeutic, and that treatment tends to be shorter in duration.

Again, I don't mean to make this sound easy. It's not. It's really hard work. I think that line is so important. The thoughts are more redirectable.

So think about you've got a glitch in your thinking around, "My body is bad," because you've been fed all this misinformation that your body is bad. You can be feeling very distressed about it. Same with BDD, right? Also could be inferred this information.

The difference is if it's distress around your body image, it's a lot easier to be like, "Hey, have you thought about this? Let's have a look at those thoughts and see where they come from. Do they align with your values?" And then you're like, "Fuck, no. I'm not going to... just because Chaz doesn't want to fuck me, fuck that guy. I'm going to do what I want."

Whereas with BDD, if you're like, "Hey, where have these thoughts come from? What about dickhead Chaz? Do you care about him wanting to fuck you?" Then it's not going to have the same response of like, "Yeah, fuck that guy," because there's something with the brain that is happening. Going to talk about that right now.

So alongside those time-sucking, time-consuming, repetitive compulsions and mental acts, BDD also involves distinct visual processing differences and cognitive distortions. Let me say that again.

BDD also involves distinct visual processing differences and cognitive distortions.

So, for example, people with BDD are more detail-focused in their processing. So if they look at themselves or others, they'll look at just someone's arms, just someone's nose, or just their arms or just their nose, and they have reduced global processing, which means difficulty integrating individual features into an overall representation of themselves.

And so because they've got that detail focus, it's like, "Okay, that's my nose, and that's the thing that I'm focusing on," and not bringing in their whole body or their whole selves into this processing.

So, for example, someone without BDD may say, "I hate my fat body, but my face is cute," which is always the compliment. "You've got such a beautiful face. My face is nice, and I have nice hair, and I'm a good person too." And so it's like you're able to look at yourself "globally" or "holistically."

People with BDD, they have an abnormal allocation of visual attention. So studies have shown, when looking at visual tracking of people's eyes with BDD, they look at features on themselves and others more. And so if they are focused on their stomach, for example, they would be looking at other people's stomachs more as well as their own. Physically, their eyeballs are going to those features more.

Also, people with BDD tend to have a bias for negative and threatening interpretations of facial expressions. And so the data coming in is scrambled a bit, and the data is focused on just one area. You're just getting the same type of data all the time, like, "Think of your stomach... think of their stomach..." and then that data is coming in and saying, "A rich person"... this is bad, this is bad. You know, and, oh my God, I just saw that person's face, and they are looking at me in a negative... I can see their face is that they're negative, they're judging me, they're judging me, it's because of my stomach. And there's many more examples, right, of these visual processing differences and cognitive differences.

Another thing is with body image, generally people are able to recognize that they have these negative... like, I have a negative belief about myself. And it's probably driven because... driven by society, by my mum or whatever telling me that I'm ugly and blah, blah, blah. And so you're like, you know, I can see that, you know, by society standards, society tells me that my body is bad.

Whereas someone with BDD will be like, "No, I know, you know, I know." Or maybe not, they might have that insight, right, but it's more likely.

The other thing with BDD versus body image, body image shame, is that if you remove societal pressures from someone who has body image shame, or if they lose weight, say if they think their body's too big, they could experience less shame because they've moved closer to the socially valued body, right? And so, not to say that that's the right way to do it, you know, like overcome shame by adhering to beauty norms, but if the outside source of shame is removed, that internal shame can also be influenced too.

Whereas, say with the surgery example, that if someone with BDD has surgery and they've "fixed the thing that's wrong," that doesn't change the way that they feel about the thing that they see as an issue.

Yeah, so how both are treated: with body image shame, there's, you know, talking about understanding societal pressures, having non-body-centric goals, mindfulness, developing positive relationships, self-acceptance, and therapies like ACT, which is acceptance and commitment therapy, DBT, which is dialectical behavioral therapy, and CBT, cognitive behavioral therapy.

Treatment for BDD can be something like CBT tailored for BDD, but also, fucking another acronym, ERP, which is exposure and response prevention, which targets the compulsion cycle, and also SSRI medication, so antidepressant medications.

But again, you know, I've just listed all the ways that they're different. There still are lots of similarities, right? So there's, you know, appearance-focused distress, shame, embarrassment, negative body thoughts, preoccupation with thinking about those things, comparison with others, checking your body, avoidance of things, hiding your body, reassurance-seeking, social anxiety. Both can have an impact on your daily life. So there are so many ways that they are similar, right?

So, anti-fatness, how does that come in? What's going on? So what about anti-fatness? This is what's really interesting to me, that culture appears to influence which physical features become the focus of BDD.

So in white cultures or global minority populations, by the way, global minorities is a different way to say "Western" or "Westernized." I fucking hate the phrase "Western," "Westernized," because it puts the UK as the center of the world. It puts... which is, you know, that's what the phrase we're saying. We put the UK, Europe, at the center of the world when it's not, and then you've got East, Far East, as if these faraway locations that, you know, they're so far from the center of the Earth, which is the UK. We're the center of the Earth. Okay, we are what humanity is. We are the norm. Anyone who's away from us is "exotic" or "different" or on the periphery. You know, so the UK is not the center of the Earth, so I hate it so much, "Western."

And so to combat that, I like saying "global minority populations" because white people are in the global minority. So why is it that white people like me are the focus of so much stuff, and in this, in like so many of these studies that I'm talking about, is on white populations, global minority populations? And when we talk about our set of me, me, white people being global minorities, we recognize how fucked it up it is that everything's focused on us when we are the minority in the world.

Anyway, so all that to say, in whites or global minority populations, the things that people focus on: skin, hair, nose, stomach, breasts, legs, muscular body.

In some East Asian populations, the focuses could be, could be on these or everything that, you know, in those cultures, but also eyes, eyelids, nose, hair, skin. And in some other Asian populations, greater concern about straight hair and having lighter skin. And in, you know, we're talking about whole freaking whole continent, so this is very kind of broad strokes. Some, in some African populations, skin color, you know, you know, so like colorism around skin, wanting a lighter shade of skin, and appearance of hair, it not being straight enough.

Okay, so culture can influence, not always, but can influence the physical features that someone is focusing on.

So question: do we have more people with BDD focusing on anti-fatness, or do we have more instances of BDD in anti-fat societies, or in societies that put more weight, stock in appearances in general?

So we don't have enough cross-cultural research to show the amount of anti-fatness in relation to BDD, because BDD, often the focus of BDD is not body size. But, and so we can't say, okay, well, in Peru, this is, we've got this many instances of BDD. And in Peru, the prevalence of anti-fatness is, is X rate. And then in Botswana, this is the prevalence of, like, we don't have things like that, right, to show cross-culturally.

That would be, well, because anti-fatness is not a key feature of BDD. For most people with BDD, it's probably not really relevant.

But anyway, here's a study that focused specifically on BDD. And it's with men who have muscle dysmorphia symptoms. And so that was this, you know, a subtype of body dysmorphia. So we've got 269 US men. And what they found was that men who believed more strongly that fat people, quote, "lack willpower," tended to report a stronger desire to become more muscular. And the men who experienced more disruption to their lives because of muscle dysmorphia, so remember, we're talking about the things that we, people might be doing if they have body dysmorphia and the amount of hours they might be doing. So the disruption to their lives because of muscle dysmorphia symptoms tended to report a greater fear of becoming fat.

Participants wanted to increase their muscularity to demonstrate their willpower and distance themselves from anti-fat stereotypes. And then their recommendation is that clinicians may consider targeting weight-stigmatizing attitudes to reduce muscle dysmorphia symptom severity among men clients. I thought that was interesting.

We have a systematic review. And so, if you don't know, a systematic review is when people will gather up all of the studies or papers about a certain topic. And so, in the past, for this example, there were 2,064 papers published around, this is about body image and cultures. And so, there's 2,000 published papers. How many of them are relevant? And so, they decided 54 were relevant to answer the question they were asking. And the papers were from 1990 to 2023. And then they look at what those papers found, and then they summarize what the findings were.

So it's a really robust way because then you're pulling in loads of data versus just one study of 12 people. So this is a really good one.

And they found that culture influences body image, body dissatisfaction, beauty ideals, and the internalization of appearance standards. Culture influences which bodies are considered desirable and can shape body dissatisfaction and appearance concerns. And so, this is not on BDD, this is body dissatisfaction. And so, the more the culture placed a value on appearance, the more body image concerns there were. Surprise, surprise!

So, for anorexia, there is a much stronger relationship that we can identify because obviously anorexia, like a key facet of it, is distancing themselves from fatness. So there's a much stronger cultural relationship towards body size, negative attitudes about body size, and rates of anorexia and severity of symptoms.

So, I found one study that was interesting that it showed that there are people who have anorexia who report that weight is not a concern. So you can have anorexia and anorexia not be driven by a fear of fatness, right? It can be driven by other things like showing discipline or perfectionism.

So, this is a smaller study. They had a group of people who were, they called them fatphobic AN and non-fatphobic AN, and then they had a control group. And what they found is that the people who said, who had anorexia, who said that weight was not a concern, they asked them, they did it for everyone, but they asked specific questions to kind of, to understand their preferences in regards to, would you rather be healthy and be a higher weight or would you rather be... lots of different questions just to kind of see if being in a bigger body was okay for them.

The people who said that they were not concerned about weight and they were concerned about these other things showed that they still did have concerns about weight. So they had a preference for a smaller body and did not want a bigger body. So even though they were reporting, no, it's not about weight, there were, there were influences of weight, although it may, might not have been a sole concern, right?

But generally speaking, people in cultures that are more anti-fat have more eating disorders.

So for BDD, going back to BDD, weight ranks number six among appearance concerns. So, the top is skin at 80%, hair at 57%, nose 39%, stomach 32%, teeth 29%. About 29% of people with BDD had significant concerns about their weight. And, you know, it says that 32% of people have issues with their stomach, focused on their stomach. So is that to do with stomach size, and is it to do with it not being slim?

So weight concern in BDD tends to occur alongside other concerns. So they could, you know, saying I'm concerned that I'm too fat, but also I'm concerned about my hair, versus being the sole concern.

So here's the thing, here's the thing, here's the thing. You remember I said put a pin in a pin, a pin in what I was just saying about the criteria and all of this stuff. Here's the kicker. If someone goes to their doctor and they say, "I think I have BDD and my concern is around my weight," guess what? Apparently, that person, according to the guidelines, doesn't have BDD.

Okay, so go back to the criteria, the diagnostic criteria. Quote, "The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder."

Okay, so imagine we have a fat person who has BDD symptoms focused on weight concerns. This is a quote from the guidelines: "If a person's primary distress is explicitly about their weight or body fat, clinical diagnostic guidelines state that a BDD diagnosis cannot be given. Instead, the clinician must evaluate the person for an eating disorder."

My eyes are rolling, my eyes are rolling. I brought this to the attention. Actually, I'll keep going, I'll keep going, then I'll tell you something.

Okay, so, but what if they don't have any eating disorder symptoms? I know there are a lot of times in my life where I didn't have BDD, but I was very focused on body shame, hated myself, but I wasn't engaging in dieting, right? I didn't have an eating disorder. I probably was disordered eating, but I didn't have an eating disorder.

So, okay, so they're fat, they're concerned, they're concerned with their fatness, they don't have an eating disorder, but they have all of the symptoms of BDD, but their focus is on body size. What happens then?

Well, clinically, some, not all, but some may frame this as, quote, "psychological issues associated with O-word." Eye-rolling. So they would frame it as severe body image dissatisfaction, or they could say this is societal weight, anti-fatness, and then it be treated under the umbrella of depression, anxiety, or low self-esteem.

Why the fuck would we be treating something that falls under OCD as depression, anxiety, or low self-esteem? Because it's focused on weight.

Now, a lot of times, if someone is focused on weight, they are likely to be engaging in disordered eating, right, or have an eating disorder, but not always. And there's this fucked-up bit here, which I think explains what's going on here.

So going back to that diagnostic criteria that I told you to put a pin in. Quote, this is one of the criteria: "Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others."

So if someone, a fat person, comes and says, "I'm obsessed. I'm really focused and obsessed. I feel just really, I'm just, I'm just my way. I'm just really struggling with this." The provider, the healthcare provider, can be like, "Well, I can observe they are fat, and this is not slight, you know, this is not a slight fatness. They are fat as fuck. So therefore, good for you, you should be focused on it, keep going."

It's the same thing with, like, atypical anorexia, right? Which atypical anorexia, which is anorexia in fat people, which occurs more frequently than anorexia, which is anorexia in people in smaller bodies.

So we, a lot of, a lot of, a lot of, a lot of what is a disorder is based on what we as a society say, you know, because this is all made up, right? We say this is abnormal. And so, you know, as there are new additions of the DSM and as we understand people more, we start to say, "Oh, actually, you know, being gay is not a disorder. It's just a normal part of being a human."

And so a lot of science and ways that we understand humans have bias just stuck, seeped into them, right? And so I went to my professor with this. I was like, "Hang on a minute, what the fuck? Am I understanding this right?" And my professor was like, "Yeah, holy shit, I think you found something," and then reached out to colleagues to kind of look into it more.

Now, here's the good news. In the real world, if you're meeting someone, a provider, say a therapist who is not a giant piece of shit, and they practice weight-inclusive care, they would say, "Yeah, it looks like you're meeting the criteria for BDD. And yeah, you know, you're focused on your stomach size and whatever, but I can see that... So you're focused on weight, which is, you know, one of the things they say you can't be focused on that, but I can see that you're spending five hours a day doing this. I can see all these repetitive thoughts. I can see the impact that it's having on your life. I can see..."

They would diagnose the person with BDD, you know, if they're a psychiatrist, if they can diagnose. If the person is not aware of anti-fatness, they could just say, "Here, weight," and just be like, "Oh, eating disorder, obviously," and funnel someone into eating disorder treatment when they may not have an eating disorder, or maybe they do, and they also need treatment. They need treatment for an eating disorder and they need treatment for this OCD-based BDD.

But because weight is a focus for this person, they're being denied that treatment if the provider is following the guidelines that have been set out. It's just so fucked up.

The flaw is not observable or appears slight to others, right? I imagine, "What the fuck are we...?" Why? What? I understand why they're saying that, right? Because the idea around BDD is that it doesn't matter if the... It really... It doesn't matter if the flaw is, you can see it or you can't see it. There's this obsession, right? That's the driver, is this compulsion.

So I think it should be an obsession, full stop. Like, why? Why are we saying that, "Okay, it's okay for you to have... to spend eight hours a day focused on your ears, for example, because I think that your ears are ugly." What? I think your ears are too big. Yeah, mate, go for it. I'm going to spend that eight hours a day. You've got big fucking Dumbo ears. Go for it. Knock yourself out. Get them fixed while you're at it. What?

Why are we taking our perception of someone else's attractiveness as a consideration when diagnosing someone? And again, I get it. I'm being maybe a bit... What's the word? Pedantic, maybe, on this wording because it sounds like... Maybe it's my autism. It sounds like to me, they're trying to say they're going too far with this preoccupation, but that's not what they're saying, right? And as we know, so many things like this are based on biased beliefs.

Anyway, to summarize, anti-fatness. The question around anti-fatness is, "Is this stuff just anti-fatness?" Is focusing on our bodies or feeling shame around our bodies, is that just anti-fatness?

Well, anti-fatness can influence both body image shame and BDD, because we're taught what bodies and what features are attractive and are acceptable. But BDD is not just the internalization of oppressive body ideals. It's a category of OCD and influenced by biological, psychological, and societal factors. And those societal and psychological factors both mentioned bullying and beauty ideals, right? So anti-fatness could be in both of those sections, but it's more like it's a... making a cake. It's like one of the things that goes into making this a diagnosis.

So if someone with body image shame... So imagine this. So someone with body image shame went to live on a desert island with just them. After time, they probably wouldn't be experiencing body shame, right, on a day-to-day basis. They lived in society, then they lived on a desert island for 20 years. They're probably not going to be like, "Oh, my body is this and my body looks bad and I feel shame about my body." That's probably not what's going to happen, right? That feeling of body shame is probably going to fade.

If someone with BDD went to live on a desert island, they could still have those BDD symptoms, because it's a difference in the way that someone's brain is working and processing information.

Now, what if those people were born on a desert island with no one else there? Would BDD have developed? So society provides the content for what someone might be fixating on when they have BDD. So this is what maybe your brain is going to hyper-focus on, but it doesn't create the outcome.

As in, culture provides the data, the data, "This body type is wrong and you should look like this." But the person who has BDD, there's a glitch in the processing of the information that causes it to take that data and it's like, "Blip, blip, blip," mixes it up a little bit.

So yeah. What do you think? Do you think that if someone was born on a desert island and their parents had BDD, for example, but they never knew their parents, do you think that they would be less likely to develop BDD? Would they develop BDD at all? Who knows? It's kind of, it'd be an ethical experiment to do, wouldn't it?

Would they develop language? Someone was just born on a desert island with no one else. Anyway, I wonder if they would. Would they develop language? Well, there's that study, isn't there? Not study, that... Oh, that girl. What was her? It was from the '60s, and she was found, it was a case of child abuse. She was found just completely, severely, absolutely neglected by her parents, where they didn't even speak to her. And so she couldn't communicate when she came out.

Oh shit, what was her name? I'm going to Google it. Hang on. Genie. Her name was Genie. Yeah, so from when she was about 20 months old, from then until the age of 13, she was basically isolated. And then there's a documentary that was filmed in, oh, it's in the 1970s, filmed in the 1970s. You can just Google Genie, G-E-N-I-E, and then you can see her with the doctors and all of these experts who were helping her.

And she did start to learn to communicate, although it was still very, not at the pace that they would have expected. And then she was removed from the scientists. It sounded like it was a good environment for her. And she was removed, I think, by a family member or something, and she was just put somewhere else where she then regressed because she didn't have that support.

And then I think since then she's being looked after by people, but she'd never had that same experience of these experts helping. And who knows if it was the right thing or whatever. But since then, there's not been any pressure, anything on her, so we don't know what happened to her.

Oh my God, tangent. Talking about BDD, they've been going on to Genie. Anyway, it's just, sometimes I think about these things of what would happen and with language. You have to have developed, be exposed to language by a certain age or it can be something that can't be developed at all.

Yeah, interesting. I'm so pleased I get to study this. How lucky am I? I get to study psychology and all that stuff.

Last thing that I thought was really interesting is that there is something called body dysmorphic disorder by proxy. And that's defined as a form of BDD. It's not a distinct diagnosis, but it's a form of BDD in which people are preoccupied with the defects that they perceive in someone else's appearance.

And so it's most often a significant other, so a spouse, a partner, but sometimes can be a parent, child, sibling, or even a stranger. And so the way that it manifests is that they will have a person of concern. It's called POC, person of concern. And there could be even more. They can be even concerned with multiple people.

And they'll have a focus on a body type, a body part, same as with BDD, but it's with someone else. And their behaviors will be, instead of doing things for their own body, they'll be trying to get the person to camouflage the flaw that they perceive, maybe trying to avoid going out, getting the person to not go out too much. And if they do go out, they might be thinking that other people are looking at the "flaw" of that other person and thinking bad things.

They also might feel shame and guilt about having these obsessions about someone else and worry that it makes them a bad parent or bad partner or whatever, but it's so difficult to control, right?

And there was a case of, there was a first recorded case of fatal body dysmorphic disorder by proxy in 2001. There was a case where the patient was referred to as Mr. A, was a 63-year-old man who became intensely preoccupied with his daughter's hair. And he believed that he had somehow caused her hair to become thin, even though her hair actually appeared to be normal.

He thought about it constantly, repeatedly asked other people for reassurance that he hadn't caused it. And he would show pictures of his daughter to other people and say, "Look at her hair, her hair's thin and I caused her hair to be thin."

He didn't have any concern about his own appearance. The preoccupation was really impairing to his life, so much so that he was hospitalized for five weeks and at the time was diagnosed with OCD, not BDD by proxy. And the people who were talking about his case say, "This should probably be BDD by proxy."

After he was discharged from hospital, he was in there for five weeks, he died by suicide. And yeah, so that was the first case. And there's been more literature since 2001 talking about BDD by proxy. So I thought that was eye-opening. And shows how distressing and how intrusive these thoughts are, right?

So cool. All right, so I'm going to make a social post of the differences. So if you ever want to look at BDD versus body image versus both of them, I'm going to do one of those, you know, the circle diagram, doobly-doos, Venn diagram.

And if you feel like you're struggling, then even if you don't have BDD and you're like, "Yeah, I don't think I am spending this amount of hours and I don't know anything," whatever, it can still be incredibly distressing. And someone who has body image shame could also be experiencing, you know, other things that can make it even more difficult, like having other mental health issues, like, you know, depression or anxiety, and could be dealing with other things in life, like experiencing racism or anti-fatness or ableism, and could be dealing with other things, like being autistic or ADHD or other health things too.

And so I don't want anyone to feel like their experiences of body image struggles are diminished. It's just that they're two different types of things. One is based around OCD, and both are treatable, right? I don't want anyone to think, "Oh well, okay, well, I do have BDD and it sounds really fucking awful." Both are treatable, and both can be helped with education around this stuff, right? Like, so listening to my podcast or any other resources on beauty ideals in any way that they manifest can be helpful, right?

So I hope that you have hope. I hope that you have hope and don't feel, you know, I don't know, don't feel bad, don't feel bad. Yeah, because we're all different, we're all dealing with our own shit, right? We don't know what's... Everyone's trying to get through world and get through life and survive.

Again, if you'd like the transcript, you can go to fearsfaty.com/211. If you appreciate the information I'm sharing, feel free to donate on Ko-fi. And yeah, I'll check you on the flip side. Remember, you are whether you always were, you always will be. Stay fearsfaty. I'm gonna be. Bye. See ya, Laina. Bye.