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Emotional WellbeingPhysical WellbeingSelf Improvement The Beast In The Mirror: Overcoming Body Dysmorphic Disorder “Mirrors are perpetually deceitful. They lie and steal your true self. They reveal only what your mind believes it sees.” – Dee Remy Are you finding yourself in front of your mirror on a regular basis and noting all of your imperfections? Are you embarrassed to leave the home because of a minor flaw or blemish on your face? Is plastic surgery on the horizon for you in the near future? If you answer yes to any of these questions, you may be dealing with Body Dysmorphic Disorder (BDD). The DSM-IV defines BDD as “a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive. This preoccupation often causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. This preoccupation is not better accounted for by another mental disorder (eg, dissatisfaction with body shape and size in anorexia nervosa).” BDD is distinguished from anorexia nervosa and bulimia nervosa , to the extent that patients w anorexia or bulimia disorders are preoccupied with their overall weight and body shape. BDD however focuses on a specific area and is not related to weight or dieting. An example might be an adolescent who thinks that her breasts are too large and wants to have plastic surgery to reduce their size but is otherwise unconcerned about her weight and is eating normally. Recent statistics indicate a many as 50% of patients diagnosed with BDD undergo plastic surgery to correct their perceived physical defects. Individuals with BDD often focus so much on the defect, they often lose sight of the whole self. A person with a pimple on their nose might feel it is considerably larger than it actually is and their reactions fit their perception rather than reality. This may be caused by an error in the visual processing region of your brain. This visual processing error can lead to low self-esteem, high suicide risk, and repeated cosmetic surgery. Although the symptoms appear psychological in nature, new research by UCLA psychiatrist Jamie D. Feusner appears to indicate it might actually be linked to problems with seeing the big picture in the brain. In the study, subjects were shown blurred pictures of their own faces while inside the fMRI machine. Dr. Feusner observed, compared to healthy control subjects, those subjects identified with BDD showed much less activity in the brain region responsible for forming visual details into composite forms. This inability to see the whole picture generalized to other activities as well, including looking at pictures of houses. People with BDD tend to have difficulty seeing the whole picture and cannot process the context of what they are looking at. This perceptual error seems to be the underlying reason individuals suffer from a distorted self image, which defines BDD. Causes of BDD Although recent research points to an error in the visual processing region of the brain, other research indicates the cause might be related to low seratonin levels in the brain. Seratonin, a neurotransmitter produced by the brain, is often associated with depression and mood disorders when levels are below normal in the brain. Another significant factor in the development of BDD is the influence of the mass media, particularly the role of advertising in spreading images of physically “perfect” men and women. Impressionable young children and adolescents absorb the message that anything short of physical perfection is unacceptable. This may lead to developing distorted perceptions of their own faces and bodies. Family of origin plays an important role in our self perceptions, which can increase our vulnerability to BDD. Children whose parents are obsessed with appearance, dieting, and/or bodybuilding; or who are highly critical of their children’s looks, are at greater risk of developing BDD. A history of trauma and abuse can also be an additional factor. When an individual with a history of trauma or abuse buries their feelings about the abuse or traumatic incident, the oppressed feelings can emerge in the form of obsessions about physical features. This “reassignment” of feelings is called displacement. An example that best describes this displacement is an adolescent with a history of physical abuse as a young child becoming obsessed with body building and strength. Individuals with BDD can have symptoms similar to OCD (obsessive compulsive disorder) since anxiety is at the root of both disorders. Symptoms of BDD include: Ritualistic Behavior: Ritualistic behavior refers to actions that the individual performs to manage anxiety and that take up excessive amounts of his/her time. Individuals are frequently upset if someone or something interferes with or interrupts their ritual. For individuals diagnosed with BDD, these ritualistic behaviors may include exercise or makeup routines, assuming specific poses or postures in front of a mirror, etc. Camouflaging: Individuals with BDD usually spend a great amount of time camouflaging “problem” feature or body part with makeup, hats, or clothing. 94% of individuals with BDD have reported camouflaging. Mirror Obsession: Abnormal behavior around mirrors, large storefront windows, or similar reflecting surfaces is common with individuals with BDD. A majority of individuals diagnosed with BDD frequently check their appearance in mirrors or spend long periods of time doing so. A few react in the opposite direction and avoid mirrors when possible. Fishing for Compliments: Individual with BDD frequently ask for reassurance from others about their appearance. Self Comparisons: Individuals with BDD frequently compare their own appearance to others. Social Avoidance: Due to their insecurities, individual with BDD often avoid activities outside the home, including school and social events*. *The loss of functioning resulting from BDD can have serious consequences for the individuals future. Adolescents with BDD often cut school and may be reluctant to participate in sports, youth groups, or hold part-time or summer jobs. Many individuals are unable to remain in school, form healthy relationships, or keep steady jobs. Adults with muscle dysmorphia have been known to turn down job promotions in order to have more time to focus on their imperfections by working out more at the gym or fitness centers. The economic consequences of BDD can include overspending on cosmetics, clothing, or plastic surgery. Treatment Individuals with BDD often respond well to medications such as antidepressants as well as individual therapy using Cognitive Behavior Therapy (CBT). CBT has been found useful in reducing BDD symptoms. With CBT, individuals learn to see themselves in the mirror without the need for negative self talk or tendency to focus on the negative defects. CBT also challenges inaccurate self-perceptions the individual might have about themselves. Relaxation techniques paired with CBT work well for individuals with BDD. In more severe cases, hospitalization may be warranted for individuals with BDD. Since BDD patients have a high rate of self-destructive behavior, including performing surgery on themselves at home (e.g. liposuction followed by skin stapling, removing facial scars with sand paper, or even sawing down their teeth), hospitalization might be the best place for them to get the help they need. Individuals with severe cases of BDD have a high rate of attempted and completed suicide. Out of 100 individuals diagnosed with BDD, 48% have been hospitalized for psychiatric reasons and 30% had made at least one suicide attempt. Prevention The best preventive strategy appears to be simply challenging the perception of those afflicted with unrealistic images of themselves. Despite the pervasive influence of the mass media in our lives, we must educate ourselves and our children about the realities of those supposed “perfect” images we are exposed to. Point out the airbrushing and photo-shopping involved in getting models to look a certain way. Most importantly, talk to young children about the pitfalls of trying to look “perfect”. Teach them the importance of being well rounded, mentally and physically. Stop complimenting girls and boys on just their physical appearance and attributes. Compliment them on being smart, kind, compassionate, and generous rather than on being beautiful and cute. By doing so, you are teaching them to value themselves as a whole rather than a physical part or feature. Lastly, educate yourself on the symptoms of BDD and pay attention to changes in your children’s dress and behavior. Early intervention is key. Dr. Nafisa Sekandari mentalhealth4muslims

Obsessive Compulsive Disorder and Scrupulosity in Islam Dr. Nafisa Sekandari “He who has health has hope, and he who has hope has everything.” – Arabian Proverb Wikipedia defines scrupulosity as a psychological disorder “characterized by pathological guilt about moral or religious issues. It is personally distressing, objectively dysfunctional, and often accompanied by significant impairment in social functioning”. Religious practice and devotion are not necessarily the cause of scrupulosity. Scrupulosity is considered a form of Obsessive-Compulsive Disorder (OCD). OCD can occur in different forms. There are a variety of different types of obsessions and compulsions. The nature of intensity of these symptoms may vary over time. In some cases, aggressive, sexual and religious obsessions can occur together in the same individual. The obsessions in OCD are the recurrent thoughts or impulses that make an individual anxious (such as the fear of germs in public places making one sick). Despite an individual’s efforts to control and suppress the obsessive thoughts, the obsessions persist. The thoughts often feel intrusive and disturbing despite the individual’s awareness of the thoughts being produced in their own mind. Obsessions can include fear of harming someone, becoming contaminated, and/or doing something embarrassing. Compulsions, however, are repetitive behaviors or mental acts the person feels driven to perform. These acts are often with ritualistic rigidity aimed to prevent the anxiety connected with the obsessions. These actions may include the urge to wash, count, check, or repeat phrases to oneself. OCD appears to be a biologically based disorder with severe psychological consequences. According to the OCD foundation about 1 in 100 adults – or between 2 to 3 million adults in the United States have OCD. The OCD foundation also estimates at least 1 in 200 – or 500,000 – kids and teens that have OCD in the United States. OCD statistics is assumed that up to 2.5 percent of the world population is affected obsessive-compulsive disorder. Some compulsive symptoms are detected in approximately eight percent of population. People suffering from OCD also end up suffering from depression, a lack of self-esteem and self confidence, very weak willpower, relationship problems, and social withdrawal. How Scrupulosity differs from devout faith and practice According to the hadith “Abu Huraira (may God be pleased with him) reported the Prophet (peace be upon him) said: “The religion of Islam is easy, and whoever makes the religion a rigour, it will overpower him. So, follow a middle course (in worship); if you can’t do this, do something near to it and give glad tidings and seek help (of Allah) in the morning and at dusk and some part of the night” [al Bukhari]. Scrupulosity is when the individual is overpowered by their devotion and practice of their faith. The scrupulous individual will focus excessively on a few specific rules and rituals while neglecting other aspects of the religion. It often involves mistakenly thinking that innocent or unavoidable things are sin and so feeling needlessly guilty. When scrupulosity turns to obsessive thoughts, it can generate upsetting, uncontrollable blasphemous thoughts or images about God, or exalting the devil. Just as some people with OCD feel compelled to keep checking locks or washing their hands, others might feel compelled to obsess over blasphemous thoughts that they hate or to keep doubting their salvation. Due to the doubting nature of scrupulosity, it has been also been called “pathological doubt”. OCD sufferers will take a simple act of locking a door, switching off the oven, or seeking Allah’s forgiveness, and then worry abnormally over whether they did it correctly. They feel driven to keep seeking assurance far beyond what is rational. Scrupulosity is considered a hidden disease due to the fact that it can fill people with such false guilt that many are unlikely to admit to it, while others have no idea that they have an unhealthy sense of guilt and so suppose there is nothing wrong with them. In Islam, such unwanted thoughts are called wasawis (plural of waswasah), which are whispered into the minds and hearts of people by Shaitan (Satan). These wasawis play a significant role in many mental disorders that involve anxiety and cognitive distortions. Although wasawis can affect individuals regardless of age, sex, faith, or creed, the nature, content, severity, and influence of these thoughts varies in individuals. For some, they only cause mild anxiety and worry, while others are more severely affected to the point of becoming spiritually, mentally, emotionally, psychologically, and socially paralyzed. Recurring thoughts about catching germs, being unclean, and questioning one’s faith appear to be the most common form of OCD amongst Muslim men and women but those suffering from scrupulosity, the unwanted thoughts tend to be more debilitating. In the process of wasawis, Shaitan doesn’t care about the thoughts and doubts he sets buzzing around in our heads. Shaitan knows we will not be judged for the thoughts he has implanted in our heads because they are his thoughts, not ours. It is an impossible task to stop unwanted thoughts from coming in our minds. While we are busy battling unwanted thoughts from our mind, Shaitan accomplishes his goal of distracting us from the essential teachings of Islam. The goal of every Muslim should be to strengthen our faith and connection to Allah and not waste time avoiding certain thoughts or feelings. Shaitan will try and distract us from his real schemes and instead focuses our attention on past sins instead of present forgiveness. Shaitan will also try and trick us into becoming so preoccupied with needlessly worrying about dishonoring God with words that we do not even mean, that we don’t notice that we are dishonoring God by not believing the extent of His love and forgiveness, even towards those of us who feel certain we are the worst sinners ever to walk this planet. No matter how terrible the words or images that invade our mind are, we are not “sinning”. Shaitan will also try and entice us to fear Quranic verses that apply only to people who until their dying day stubbornly refuse to repent from their deliberate sin/backsliding and refuse to seek forgiveness. Shaitan’s hope is that we become so alarmed by the few words in the verses that do not apply to us that we lose sight of the enormous number of joyous verses that do apply – those promising salvation to everyone who repents and believes in Allah and His messenger. Shaitan’s dirty trick is to put despicable thoughts in our mind and then blame us or Allah for it. Allah isn’t fooled into blaming us for Shaitan’s trickery and we shouldn’t be fooled either. Just like we can’t stop Shaitan from being Shaitan, we can’t stop thoughts of temptation from popping into our thoughts. All we can do is stop ourselves from being deceived by the thoughts. All in all, Obsessive Compulsive Disorder is an anxiety disorder. It is fear/anxiety that keeps us hounded by doubts, guilt feelings or unwanted thoughts that keep repeating in our minds. It is the very nature of deceiving spirits to foster and exploit fear for their evil purposes, and their highest goal is to fool us into losing faith in our religion. Treatment of Scrupulosity Like other forms of OCD, scrupulosity responds to medication and cognitive-behavioral therapy (CBT). About 60%–80% of patients show some degree of response to treatment. The neurotransmitter serotonin appears to be involved in the pathology of OCD. Medications that boost the level of serotonin in the brain such as SSRI’s (e.g. clomipramine, fluoxetine, sertraline, paroxetine, fluvoxamine, and citalopram) are the most effective in treating OCD. Cognitive-Behavioral therapy (CBT), specifically Exposure and Response Prevention (ERP) has been successfully used for the treatment of OCD. ERP focuses on the fact that compulsions provide only a temporary reduction of the anxiety produced by obsessions. The only way to experience more permanent relief is to habituate (get used to) the anxiety caused by the obsession, without performing the compulsion. The key factor of ERP is habituation. While this type of therapy typically causes some short-term anxiety, this facilitates long-term reduction in obsessive and compulsive symptoms. Facing the negative, unwanted thoughts will create anxiety. It is highly unpleasant, but they must disregard their fears in order to benefit from treatment. Facing their anxiety is an unavoidably unpleasant experience, but they must continually force themselves to stay close to God, even though their fears of rejection and divine displeasure are immense. As the person with scrupulosity begins to face his/her fears, he/she may experience a temporary increase in anxiety but with continued support and medication, the anxiety will decrease and symptoms will improve When overwhelmed by unwanted thoughts: Keep in mind, first and foremost, Allah (swt) has prescribed a balanced approach to Islam and reassured us His mercy and forgiveness are ever so near. So if fear, anxiety, or condemnation comes upon us, it is not from God. It is simply a dirty trick of Shaitan trying to get us to take our eyes off the infinite saving power of Allah (swt). When unwanted thoughts or fears hit, do your best not to let the attack distress you. Let it wash over you, keeping as calm and unconcerned as you can. The thoughts or images won’t hurt you, and God does not accuse you. Allah (swt) knows best, even better than you do, that these thoughts are not yours. Temptation usually takes the form of thoughts being satanically placed on our minds, and temptation is not sin. When you reach the point where you don’t react to the unwanted thoughts of doubt, oppressive guilt feelings, and spiritually repulsive thoughts, the attacks themselves will lessen. Psychological fact: Anxiety is a driving force behind Obsessive Compulsive Disorder so if you are not anxious about the thoughts, you’ll notice a significant reduction in the attacks. Spiritual fact: When Shaitan is thoroughly convinced that he can no longer use such things as unwanted thoughts to annoy you, or undermine your faith, he will eventually begin to tire of that approach and only try it now and again, just to check that you have not reverted to being concerned by such attacks. We give pleasure and power to Shaitan when we fall into his trap of supposing that his plan is to get us to think or feel wrong things. Shaitan’s main goal is to get us distracted so he can ambush us. Shaitan’s evil scheme is not to entice us to think or feel anti-God things but to fool us into denying the saving power of Allah (swt) by us forgetting Allah’s power to continually forgive every person who repents and puts faith in him. Daily Exercises: When unwanted thoughts creep in your mind, catch them and write them down. Right below the thought, challenge the thought by asking if that is a true thought. Is it 100% true about you? Below that write down, “it’s just a thought”. Practice daily affirmations such as “I’m doing the best that I can”, “My thoughts are just thoughts and only have power over me if I give them power and I choose not to empower these unwanted thoughts”, “I put my trust and faith in Allah’s mercy and forgiveness”. The affirmations might not feel true for you but repeating them daily will help you replace the negative thoughts with the positive affirmations, thereby lessening the power of the negative unwanted thoughts. Practice deep breathing exercises and repeat to yourself “I am safe and with Allah’s blessings, Shaitan can’t hurt me”. Actively get involved in a deeply engrossing activity that you enjoy such as exercising (yoga, running, biking, etc.) or playing a board game where you are not focused on the negative thoughts. Force yourself to smile. This simple act will automatically make you feel happier and relax. Your mind is incapable of having a good and bad thought at the same time. When you smile, you force your mind to focus on the positive rather than the negative. Work with a mental health professional to address the symptoms of scrupulosity. Past traumas (like sexual/physical abuse) and unsavory conduct and lifestyles of the past that may be responsible for severe guilt leading to OCD, must be dealt with in therapy with a trained mental health professional. Overall, relaxation, daily practice, education, medication, and cognitive behavior therapy can be combined to treat OCD and Scrupulosity. Coordination Between Islamic Leaders and Mental Health Professionals It is often useful for mental health practioners and religious leaders to work together in raising awareness and educating the community about Scrupulosity. The religious leader can help the community members distinguish legitimate concerns about faith and guilt from stereotyped religious obsessions. If an individual is compulsively repeating a ritual until it is perfect, the Imams may need to give individuals special permission to perform a ritual in a less than perfect manner. This can lead to freedom from excessive guilt and stereotyped religious obsessions. Ultimately, the individual is freed to experience a richer life in his or her family and faith community. mentalhealthformuslims