The overlapping worlds of Obsessive Compulsive Disorder (OCD) and Body Dysmorphic Disorder (BDD) in children and young people

I met with Dr Bruce Clarke to discuss in depth the areas of obsessive compulsive disorder and body dysmorphic disorder and how they are linked, for the Nip in the Bud podcast. His responses are fascinating and full of important information that both parents/carers and educators will find incredibly useful when supporting a child who may be challenged by these disorders. Dr Bruce Clark joined the National and Specialist OCD, BDD and Related Disorders Clinic at The Maudsley Hospital, London in 2013. He is a consultant child and adolescent psychiatrist with an interest in treatment resistant Obsessive-Compulsive Disorder and related disorder. Dr Clark has a broad range of child and adolescent mental health experience. He previously worked in one of the Maudsley Hospital general community based clinics. Whilst working in that setting he became Lead Clinician for the service. He has considerable expertise in the assessment and management of Autism Spectrum Disorders, OCD, ADHD, Depression, Anxiety Disorder, as well as behavioural management issues. I asked for a clear definition of OCD and he explained firstly that it is actually quite common and that it is ‘… characterised by obsessions…intrusive ideas, images or impulses that pop into your head and are instantly distressing’.

Obsessive-Compulsive Disorder (OCD) and Body Dysmorphic Disorder (BDD) are two often misunderstood mental health conditions that can significantly impact a child or young person’s life. Dr Clarke explains that these disorders have distinct features but that they do actually share a deep connection. Both are rooted in the cycle of ‘obsessive thoughts’ and ‘compulsive behaviors’. Understanding these disorders, especially how they manifest in children and young people, is crucial for early intervention and effective support from the adults that are in a position of care.

Understanding Obsessive-Compulsive Disorder (OCD)

OCD is a mental health condition characterised by a cycle of obsessions and compulsions. Obsessions are unwanted, intrusive thoughts, images, or urges that cause significant anxiety or distress. Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession. These compulsive acts are performed to reduce anxiety or prevent a dreaded event. It is important to note that compulsions can also be mental acts, in this case they cannot be seen by others so may often be missed. Compulsions, once carried out, often provide only temporary relief, therefore result in reinforcing the cycle.
What do common obsessions include?
Common obsessions include fears of contamination, a need for symmetry or order, or intrusive thoughts of harm. Compulsions often involve repetitive cleaning, arranging, checking, or counting.

What are the signs of OCD?

It can be tricky to spot OCD but you might notice a child being drawn into rituals, these might be exaggerated when the child is anxious or stressed. The child might become ritualised and bound to those rituals to try to feel safe. Although it is important to remember that developmentally children can often go through ritualised behaviours when they are 4 or 5 years old as part of typical development. If you are unsure, as an adult it is best to take a ‘watchful waiting’ approach and notice if any rituals become more defined or intense.

What are the symptoms of OCD in children?

Diagnosing OCD in children can be challenging, as their symptoms might look different from those in adults. So what may seem like those normal childhood fears or routines can be signs of a developing disorder. Here’s how OCD can show up in children:

• Contamination fears: A child may refuse to touch doorknobs or play with certain toys, repeatedly wash their hands until they’re red and raw, or insist on changing clothes multiple times a day.
• Checking behaviors: They might repeatedly check if a door is locked, a light is off, or if their homework is in their backpack, even after they’ve already checked.
• Symmetry and ordering: A child may become distressed if their toys are not perfectly aligned, or if their school supplies are out of order, feeling a need to arrange and rearrange them until they feel ‘just right.’
• Intrusive thoughts: Children might be plagued by distressing thoughts of harm coming to themselves or their family, leading them to engage in rituals to ‘neutralise’ the thoughts.

Obsessive compulsions become a disorder, Dr Clarke explains, when they interfere with a child’s ‘… social, educational or working life’. Sadly, it is only in the early stages of OCD that it measures as mild. ‘OCD typically ramps up to moderate and severe levels of suffering and impairment, this is a well understood aspect of its trajectory.’
Although this sounds difficult, the truth is that OCD is highly treatable. The majority of people with OCD are massively helped, or OCD is completely resolved, with the right treatment. Dr Clarke is heavily involved in the research on treatment and how to ensure effective treatment is widely accessible.

What can parents and teachers do?

Although hard, early detection is key. Parents and teachers should look out for sudden changes in a child’s behavior, excessive anxiety, or time-consuming rituals that interfere with daily life.

Here’s how to help:

• Communicate openly: Talk to the child without judgment. Use phrases like, “I’ve noticed you’re spending a lot of time checking your backpack. What’s on your mind?”
• Avoid enabling compulsions: While it may feel helpful to assist with a compulsion (e.g. re-arranging a book for them), this can strengthen the cycle. Instead, gently resist the urge to participate or accommodate, and help them find alternative ways to cope.
• Talk with the child about anxiety: Explain that anxiety and feeling anxious is a normal emotion that everyone feels at times. To notice and sit with any anxious feelings is an important habit to develop because often that anxious feeling will subside without the need to act on it or try to escape from it. Offer support to sit with that anxiety together.
• Seek professional help: Go to your GP and ask for a referral. A therapist specialising in childhood anxiety and OCD can provide a proper diagnosis and treatment. Cognitive Behavioral Therapy (CBT), specifically Exposure and Response Prevention (ERP), is an effective treatment for OCD. In ERP, the child is gradually exposed to their fear while a therapist helps them resist the urge to perform the compulsion (e.g. handwashing).
• Read and learn about OCD: Go to OCD Action, OCD UK for ideas on where to get information and to signpost you to a community of people who have experience and can share their own practical examples.

The link to body dysmorphic disorder (BDD)

What is BDD?

BDD is considered an OCD-related disorder. It is a mental health condition where a person is preoccupied with a perceived flaw or flaws in their appearance. These perceived flaws are not usually about weight and shape but about other aspects of appearance. Dr Clarke explains that someone with BDD has ‘… compulsions that are ritualised to manage the sense of distress’, this then becomes ‘…disordering. It interferes with your ordinary life, you are not going to work, not going to school, often late for school and doing things compulsively.’

This preoccupation can often not be noticeable to others at first, but it causes the individual significant distress and can lead to a range of compulsive behaviors. There could be hours of mirror checking, mirror avoiding, avoiding reflective surfaces, compulsively seeking validation, repeated washing or application of makeup.

The core link to OCD is the shared cycle of obsessive thoughts (about the perceived flaw) and compulsive behaviors (performed to reduce anxiety or fix the ‘flaw’).

What are examples of BDD?

BDD is more than just vanity or self-consciousness. It’s an intense and debilitating preoccupation with one’s physical appearance. The perceived flaws could be anything from a minor facial blemish to a perceived asymmetry in their body. These concerns are so severe, like OCD, they cause significant impairment in social, occupational, or other important areas of functioning.
BDD is more a phenomenon of peri and post-puberty so is often not found in the primary years. However, although rare, research is underway to look at this age range as there are concerns that measures might be rising. Current research is showing that it is more prevalent in females than males and the late teens – early twenties is a prime time for this disorder to appear.
What are the signs of BDD? Recognising BDD can be difficult, as those affected often try to hide their distress. Here are some signs parents and teachers can look for:

• Repetitive behaviors: The individual may spend excessive time checking their appearance in mirrors, grooming, picking at their skin, or seeking reassurance from others.
• Social withdrawal: Fear of being judged for their appearance can lead to social isolation, avoidance of school or social events, and wearing excessive makeup or baggy clothing to conceal the perceived flaw.
• Preoccupation with appearance: They may constantly talk about their appearance, compare themselves to others, or even seek out unnecessary cosmetic procedures.
• Emotional distress: The child may display significant anxiety, depression, and even suicidal thoughts related to their body image concerns.

How can we offer support for BDD?

Supporting someone with BDD requires a compassionate and non-judgmental approach.

• Focus on feelings, not appearance: When a person expresses concern about a perceived flaw, it’s unhelpful to reassure them by saying, ‘You look fine.’ This often invalidates their feelings. Instead, listen and validate:acknowledge their distress, you could say for example, ‘I hear how much this is bothering you. What can we do to help?’
• Encourage professional help: As with OCD, BDD is highly treatable with therapy. CBT and ERP can be effective treatments, helping the individual challenge their negative thoughts and reduce their compulsive behaviors.
• Create a supportive environment: Encourage the child to engage in activities that they enjoy, which can help shift their focus away from their appearance. This will help them to build self-esteem and confidence in non-physical areas is crucial.

In conclusion, both OCD and BDD are complex conditions that thrive on the cycle of obsessions and compulsions. Dr Clarke ends our conversation with an encouraging plea to all of us who may be in a position of care. Both disorders are treatable, he says ‘…so don’t give up the fight!’.

By understanding the unique manifestations of OCD and BDD, and by offering compassionate and professional support, we can help those affected break free from the cycle and lead healthier, happier and more fulfilling lives.

Alis Rocca