SCALE Youth
Programme -
Summer‘25
Lecture 4
Dr. Hasse De Meyer
Today’s Topic
Obsessive Compulsive Disorder
• Core features of OCD
• Causes, assessment and treatment of OCD
Body Image Disorders
• Core features of BID
• Causes, assessment and treatment of BID
Obsessive
Compulsive
Disorder
Obsessive Compulsive Disorder: DSM-5-TR
A. Presence of obsessions and/or compulsions
B. Time consuming (> 1 hour/day) or cause clinically significant distress
or impairment
C. Not attributed to other medical problems, or physiological effects of
substance abuse
D. Not better explained by another mental health disorder
APA, 2022; Lee, 2021
Obsessions (强迫观念)
• Persistent and repeated thoughts, images, ideas, impulses or urges
• Experienced as intrusive and unwanted
• Theme’s: contamination, responsibility for harm, violence, religion,
somatic, symmetry, etc.
• Attempts to ignore/suppress or neutralize with some other thoughts or
actions (compulsions)
APA, 2022; Lee, 2021
Obsessions (强迫观念)
Violence Symmetry
“What if I snap and hurt my child? How "I need to arrange all my books so they are
could I live with myself?” perfectly aligned, or else something bad will
happen.”
Contamination
Somatic
“What if my hands are still dirty? I might
spread germs and make someone sick.” “"I keep noticing my heartbeat—what if it
means there’s something seriously wrong
Religion with my health?"
“What if I've committed a sin that I can't
undo?”
https://www.spacebetweencounselingservices.com/obsessivecompulsive
Compulsions (强迫行为)
• Repetitive behaviours or mental acts in response to obsession or
according to rules
• Motivated by reducing anxiety, disgust, feeling “not right”, or
preventing harm or a dreaded situation from occurring
• Might generate temporary relief from anxiety or distress
• Largest impairment
APA, 2022; Lee, 2021
Compulsions (强迫行为)
Obsessions Compulsion (visible or invisible)
Contamination Clean (de-contaminate)
Order / Symmetry Check, organize, re-arrange
Harm / Violence Mentally review, checking
Religion Praying, neutralizing
APA, 2022; Lee, 2021
Obsessive Compulsive Disorder
• Safety Behavior (安全行为): actions or items that prevent harm or reduce
responsibility e.g., make a video to review that the door is closed
• Reassurance seeking (寻求安慰): asking others e.g., “Do you think I caused harm?”
“Did I turn off the stove?” or repeating to themselves “I would never hurt anyone”
• Avoidance (回避): limit exposure to certain activities or objects that trigger
obsessions/compulsions e.g., avoid cooking, avoid leaving the house as the last
person
APA, 2022; Lee, 2021
Prevalence
• 1.2% (12-month)
• 25% begin before age 14
• Incidence has 2 peaks:
✓ Age 7-12; M>F
✓ Age 21; F>M
• Remission is low without treatment
APA, 2022
Risk Factors
Family history of OCD
Stressful life events
Other mental health disorders e.g., anxiety disorders, depression,
substance abuse or tic disorders.
APA, 2022
OCD in Children & Adolescents
• DSM-5-TR: Young children may not be able to articulate the
aims of these behaviors or mental acts.
• Compulsions without obsessions more likely in younger
children
• Less likely to see symptoms as conflicting with their sense of
self (ego-dystonic)
• Tic-like compulsions
• Physical experiences (e.g., physical sensations, just-right
sensations, and feelings of incompleteness) that precede
compulsions (Sensory phenomena)
APA, 2022
Assessment
Assessment
Exclude other
Impairment / diagnosis e.g.,
Symptoms
severity generalized
anxiety disorder
Family Motivation for
Outcome
Accommodation treatment
Carr, 2016
Assessment
• Questionnaires (presence and/or severity)
✓ Obsessive-Compulsive Inventory Revised (OCI-R)
✓ Florida- Obsessive Compulsive Inventory (FOCI)
✓ Children ́s Yale-Brown Obsessive-Compulsive Scale (DYBOCS)
• Interview
✓ Diagnostic: Y-BOCS (Goodman et al., 1989)
✓ Insight: Brown Assessment of Beliefs Scale (BABS, Eisen et al., 1998; can be used for variety of diagnoses)
• Check for family accommodation (e.g., help perform rituals, accept avoidance, stand in,
provide reassurance, etc.)
Carr, 2016
Structured Interview measuring OCD Questionnaire (self-report)
symptoms. Y/N
Carr, 2016
Treatment
Treatment
• Exposure and Response Prevention (ERP) 暴露与反应预防
✓ (E) exposure to obsession (RP) without compulsive ritual
✓ Planned and associated with distress
✓ Client to take responsibility to repeat and generalise tasks
Carr, 2016
https://www.spacebetweencounselingservices.com/obsessivecompulsive
Treatment
• Psycho-education
• Create fear hierarchy (恐
惧层级): overview of
situations that trigger OCD
obsessions or compulsion
• Rate the distress
• Practice in/outside session
• Discuss the outcome
Psychology Tools; Carr, 2016
Psychologytools
ERP exercise
Psychologytools
ERP exercise
Psychologytools
Children & Adolescents
• Same principles
• Best outcome WITH family involvement
• Also self-help or online training e.g.,
✓ Online training: https://www.ocdnotme.com.au/
✓ What to Do When Your Child has Obsessive Compulsive
Disorder: Strategies and Solutions by Aureen Pinto Wagner
Wagner, 2003
Body
Dysmorphic
Disorder (BDD)
“I look deformed”
“I look ugly”
Body Dysmorphic Disorder (BDD) 身体变形障碍
A. Preoccupation with one or more perceived defects or flaws in physical
appearance that are not observable or appear slight to others
B. Repetitive behaviors (e.g., mirror checking, excessive grooming, skin
picking, reassurance seeking) or mental acts (e.g., comparing his or
her appearance with that of others)
C. Clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
APA, 2022
Body Dysmorphic Disorder (BDD)
• “Hidden” disorder
• Onset during adolescence, chronic course
• Prevalence: 2-5%
• High level of disability
Sündermann, 2021
Appearance concerns BDD behaviours
Sündermann, 2021
• 1/3rd of 7-10y believe they are judged on
their appearance
• 38% think they are not pretty enough
Using social media to share images and • 15% feel embarrassed or ashamed by the
having appearance-related reasons for
using social media are both linked to more way they looked
body dysmorphic symptoms. • 1/4th feel the need to look perfect
Challenges
identifying BDD
• BDD vs real disfigurement
• Shame, fear of judgement
• Lack of knowledge
• Unhelpful beliefs of professionals
• Misdiagnosis (~ body
dissatisfaction)
• Extreme avoidance
Sündermann, 2021
Risk factors in developing BDD
• Bullying
• Comments about appearance
• High standards for aesthetics and sensitivity to them
• Placing too much importance on appearance within the family
• Excessive social media use (e.g., filters)
• Perfectionistic tendencies
• Skin-related issues (e.g., acne)
• Socio-cultural influences
Sündermann, 2021
Cognitive & Behavioral Processes
• Safety-seeking behaviors (e.g., make-up, scarfs, grooming, etc.)
• Self-focused attention
• Repetitive behaviors (e.g., mirror checking, reassurance seeking from
others)
• Attempts to correct one’s appearance (e.g., through plastic surgery)
• Avoidance (e.g., social situations, looking in the mirror, checking defect,
etc.)
Sündermann, 2021
CBT Model of
BDD
Assessment
Assessment
• Self-Report Questionnaires
✓ Body Dysmorphic Disorder Questionnaire (BDDQ)
✓ Body Image Disturbance Questionnaire (BIDQ) “ Important to
✓ Cosmetic Procedure Screening demonstrate sufficient
✓ Body Dysmorphic Disorder Scale for Youth (BDDSY) validation! “
• Clinical Interviews
✓ BDD module (SCID)
✓ Body Dysphoric Disorder Diagnostic Module
• Level of insight
Treatment
Treatment
• Behavioural experiments
• Theory A and Theory B
• Imagery rescripting
• Mirror retraining
• Attention training
• Challenging distorted beliefs
• Self-soothing and compassionate work
• Staying well plan
Challenging Distorted Beliefs
• Before attention training
• Examining positive beliefs about the benefits of continuing to
focus on and repeatedly think about appearance
• “Focusing on my appearance helps me evaluate how awful I really
look”
• “Focusing intensely on that body part helps me work out what I
should do about it”
• “Worrying about my appearance gets me prepared for others’
negative comments”
• “Comparing myself with others helps me feel better”
• “Thinking this way keeps me grounded”
• Goal: dissect and challenge positive beliefs about focusing
attention on your appearance.
https://www.cci.health.wa.gov.au/~/media/CCI/Consumer-Modules/Building-Body-
Acceptance/Building-Body-Acceptance---03---Reducing-Appearance-Preoccupation.pdf
M is a 24-year-old individual who came to our inpatient unit on national funding for treatment of
severe, treatment-resistant Body Dysmorphic Disorder (BDD). M was unemployed and living with
their mother. M has an older sibling (2 years older), and their parents are separated.
M was severely preoccupied with spots and blemishes on their facial skin, believing these made
them look ugly and unacceptable. Their BDD was easily triggered by sitting close to others, seeing
people with “better skin,” or catching a glimpse of their own appearance in the mirror. Even tiny spots
would feel unbearable, and M believed “If you have good skin, you are god. If you have bad skin, you
are a piece of rubbish,” “I need to have good skin to be acceptable,” and “I must have good skin so
that others don’t make fun of me.”
M either avoided mirrors (although they carried a pocket mirror) or became stuck in front of them for
hours “seeking satisfaction.” M also had elaborate washing and skincare routines, used strong anti-
acne medication (Accutane), and avoided sugary foods and drinks, sweating, bright lights, and
making eye contact. M constantly ruminated about why they did not have “better” skin and
relentlessly compared themselves to others, “losing 9 out of 10 times.” Their mother would hide
mirrors in the house or cover them up. On several occasions, M scraped off their skin with sandpaper
and almost burned it off. M spent most of their time in bed with the blinds down and showered in the
dark to minimize the risk of seeing their reflection.
Challenging Distorted
Beliefs
• Role Play (10 minutes)
• Pair (M vs psychologist)
• Select a positive belief about appearance
• Run M through these questions
• Switch roles after 5 minutes
https://www.cci.health.wa.gov.au/~/media/CCI/Consumer-Modules/Building-Body-
Acceptance/Building-Body-Acceptance---03---Reducing-Appearance-Preoccupation.pdf
M’s Theory A, Theory B
Theory A: represents the
client’s current, distressing, Theory A (appearance problem): Theory B (preoccupation problem):
or dysfunctional belief about “My problem is that my facial skin is “My problem is that I am
a situation or problem. terrible and makes me look ugly. preoccupied with my facial skin
Therefore, no one wants to know me. and that I worry others would see me
Theory B: represents the Also, others have better skin than me as ugly and therefore don’t want to
client’s alternative and therefore are better humans than know me. I also worry that others are
explanation or perspective, me (higher status, relationships)”. somehow better than me”
usually more rational, Evidence: Evidence:
balanced, and less distressing. I can see my blemished skin in the Many people tell me my skin looks
mirror fine
Goal: Employed to help clients Acne returned at 24 No one ever said I was ugly
examine and contrast their Others have better skin than me No one stares at me (which they
current unhelpful beliefs I saw a TV show some years ago in would if I was ugly)
(Theory A) with a more which two pictures of faces were Even when sweating no one seems to
balanced or helpful alternative compared, and I thought I’d lose care
(Theory B). I have already made friends at the
hospital
What do I need to do if Theory A is What do I need to do if Theory B is
true? true?
See a dermatologist Don’t do any of the behaviours on the left
Hide away side
Wash, cream rigidly Accept the way I look
Use Acutane Exercise normally
Compare myself and my skin with others Don’t avoid anything
Avoid mirrors Play football!
Avoid bright lights Enjoy myself
Avoid sweating at all costs; don’t play Socialise with others
football or do other sports Look for work
The future The future
“there is no future because I would not be “The world is your oyster”
able to live and would have to kill myself” Have a job
Have a relationship
Settle down and start a family
Behavioral Experiment (行为实验)
• Purpose: Test the validity of negative beliefs through real-life actions.
• How it works: Patients engage in activities that challenge their irrational thoughts or fears,
observe the results, and compare them to their predictions.
• Steps:
• Identify a belief: (e.g., "People will judge me for my appearance.")
• Make a prediction: (e.g., "If I go out in public, I will be stared at.")
• Conduct the experiment: (e.g., Go out in public for an hour.)
• Record observations: (e.g., No one stared, felt more relaxed than expected.)
• Evaluate: Was the initial belief accurate? Was the outcome different from the expectation?
• Goal: To help patients reframe negative thoughts based on real-world evidence, reducing
anxiety and altering maladaptive behavior patterns.
Example Behavioural Experiment
• Belief: If I don’t complete washing ritual others comment on my spots and laugh about me
(95%)
• Alternative belief : My skin might feel drier, but people would not notice and even if they did,
they would not laugh (5%)
• Experiment: How to test it?
Conclusion
• Obsessive-Compulsive Disorder (OCD) is a chronic condition marked by
intrusive thoughts and repetitive behaviors that can severely disrupt daily
routines, social interactions, and academic performance, highlighting the
importance of timely diagnosis and specialized treatment.
• Body Dysmorphic Disorder (BDD) involves persistent and distressing concerns
about imagined or minor defects in appearance, often leading to social
withdrawal and impaired quality of life, underscoring the need for early detection
and targeted intervention.
Summary
• Although current treatments significantly reduce
symptoms in anxiety disorders (including OCD), conduct
disorder, and body dysmorphic disorder, ongoing
challenges remain, and further advancements are
needed to enhance outcomes and address treatment-
resistant cases.
• Upcoming digital therapies
Be kind for yourself
• ”What works for whom”
Look out for others
Reach out to professionals
when needed
References
• Partial slides: Dr. Lee, Dr. Sundermann
• American Psychiatric Association. (2013). Desk reference to the diagnostic criteria from DSM-5 . American Psychiatric
Publishing, Inc..
• Carr, A. (2025). The Handbook of Child and Adolescent Clinical Psychology: A Contextual Approach (4th ed.). Routledge.
https://doi-org.libproxy1.nus.edu.sg/10.4324/9781003396864
• Manassis, K. (2009). Cognitive Behavioral Therapy with Children: A Guide for the Community Practitioner 2nd Edition. Routlegde
• JM Rey’s IACAPAP e-Textbook of Child and Adolescent Mental Health. Rey JM & Martin A (eds). Geneva: International Association
for Child and Adolescent Psychiatry and Allied Professions, 2019
