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July 19, 2010
PSYU 575: Advanced Individual Counseling
Brandman University
Instructor: Dr. Saule Buzaite, PhD, LMFT
Jackie Camarena
Presented By:
Michael Crilly
Debra Fessett
Somatoform Disorder
Treatment with Cognitive Therapy
What is Body Dysmorphic Disorder?
Body Dysmorphic Disorder (BDD)
Added as a Psychiatric Disorder in DSM-III-R in 1987.
Prior to 1987, BDD was called dysmorphophobia, a “subjective sensation of deformity or
physical defect that causes the patient’s belief of being noted by the others, although the physical
aspect appears normal”. It is also known as “the fear of having a deformity.”
Enrico Morselli in 1886
Changed to BDD, dysmorphophobia was a misnomer, implying that a person had a phobia of
one’s perceived deformity.
Preoccupation with facial flaws, genitals, breasts, buttocks, abdomen, limbs, hands, feet,
shoulders, or back
One body part usually acquires prominence and arouses the most distress, although the focus
may switch
A type of chronic mental illness in which you can't stop thinking about a flaw with your
appearance — a flaw either that is minor or that you imagine. But to you, your appearance
seems so shameful and distressing that you don't want to be seen by anyone. Body dysmorphic
disorder has sometimes been called "imagined ugliness.“
When you have body dysmorphic disorder, you intensely obsess over your appearance and
body image, often for many hours a day.You may seek out numerous cosmetic procedures to try
to "fix" your perceived flaws but never are satisfied.
BDD and Men
Sensitive about skin, nose, thinning hair, genitals and overall body size.
This condition is called muscle dysmorphia.
A subtype of BDD
Commonly leads to excessive exercise, the use of dietary supplements, & at times anabolic
Jackie Camarena
Suggested that individuals with BDD have various personality disorders.
Described as early as 1908, as being rooted in the personality, resembling
hysterics and obsessives.
BDD may occur in variety of illnesses.
Usually arises out of neurotic conditions or crises of personality
Found that patients with BDD are more “obsessoid, introverted,
intropunitive, highly neurotic and hostile.”
Research shows that there is a high comorbidity between BDD and Axis II
Two types of BDD – Mirror gazing and Mirror avoiding
Mirror avoiding or gazing is found in 80% of BDD individuals while mirror
is found in 20% of BDD individuals
It’s a hidden disorder. Most individuals are secretive and report shame
about their behavior and disgust about their appearance
Individuals have an eternal hope that they will look different to their
internal body image or feel comfortable with their appearance.
Jackie Camarena
1 minute 33 seconds to 2 minutes 10 seconds
CSI - The Hunger Artist Part 1
How is Body Dysmorphic Disorder defined?
•Diagnostic Criteria
•Criterion 1: Preoccupation
•Criterion 2: Distress or Impairment of
•Criterion 3: Differentiating BDD from
Other Disorders
Jackie Camarena
Criterion 1: Preoccupation
1. Preoccupation with an imagined defect in appearance. If
a slight physical anomaly is present, the person’s concern is
markedly excessive.
2. The preoccupation causes clinically
significant distress or impairment in social,
occupational, or other important areas of
3. The preoccupation is not better accounted
for by another mental disorder (e.g.,
dissatisfaction with body shape and size in
anorexia nervosa.)
Jackie Camarena
Criterion 2: Distress or Impairment in
Emotional suffering: feelings of depression, sadness, anxiety, worry, fear, panic, and other negative
thoughts and feelings, or more severe anxiety, depression, or suicidal thinking.
Social Functioning: relationships, socializing, intimacy, being around other people, as well as
problems with the ability to function in a job, academically, or in one’s role in life (such as being a
Partially or completely avoid many of these situations:
Friendships (ability to have friends)
Spending time with friends
Intimacy and sexual relationships
Relationship with spouse or partner
Attending social functions and events
Doing things with family
Having a job or being able to be in school
Going to school or work each day
Being on time for school or work
Focusing on school or work
Being productive and meeting expectations at school or work
Doing homework or maintaining grades
Carrying out important role activities, such as caring for children or elderly parents
Maintain a household, doing errands, going shopping
Other daily activities, recreational activities, or hobbies
Jackie Camarena
Criterion 3: Differentiating BDD from
other Disorders
Anorexia Nervosa
Gender Identity Disorder
Major Depressive Episode
Social Phobia
Obsessive-Compulsive Disorder
Jackie Camarena
5 minutes 40 seconds to 8 minutes 7 seconds
CSI - The Hunger Artist Part 4
Normal concern about appearance
Eating Disorder
Anorexia Nervosa
Bulimia Nervosa
Gender Identity Disorder
Major Depressive Episode
Avoidant Personality Disorder
Social Phobia
Obsessive-Compulsive Disorder
Delusional Disorder, Somatic Type
Culture related syndrome occurring primarily in
Southeast Asia that may be related to BDD
Jackie Camarena
Co-Morbid Disorders
Major Depressive Disorder
Obsessive-Compulsive Disorder
Anxiety disorders, especially social
Eating Disorders
Jackie Camarena
1 minute 25 seconds to 3 minutes 15 seconds
CSI – The Hunger Artist Part 5
Causes of BDD
Largely Unstudied
Genetic & Neurobiological Risk factors
Psychological Risk Factors
Social & Cultural Risk Factors
Triggering Events
Debra Fessett
• Genes
• Evolutionary Influences
• Certain brain circuitry and
• Neurotransmitters
• Life events
• Personality traits and values
• Focus on aesthetics
BDD Symptoms
•Comments about appearance
•Stressful life event
•Feeling rejected
•Cosmetic procedure
•Physical changes of adolescence
•Society’s emphasis on
•Availability of steroids (for
muscle dysmorphia)
•Cultural Influences
Causes of BDD
Debra Fessett
In the arena of biological causes, researchers have begun looking for differences between the brains of healthy people and people
with BDD. One study conducted by researchers at the University of California, Los Angeles shows that people with
BDD may process visual information differently than people without the disorder.
Researchers showed 25 people, half with BDD and half without the disorder, three different images of faces in high, regular and
low resolutions. MRI results showed that participants with BDD used the left sides of their brains -- the analytical side -- to
process all three images. The other participants used their brains' left hemispheres for only the high-resolution images. This could
mean the minds of people with BDD strive to acutely process visual details, even when there aren't any to process. This might be
why they can see flaws in themselves, even when those flaws might not exist.
Another biological factor under consideration is that people with BDD seem to have a chemical imbalance of the
neurotransmitter serotonin, because they often respond well to the SSRI (selective serotonin reuptake inhibitors) class of
antidepressants. Serotonin is one of the chemicals in the brain that transmits signals between the billions of neurons that
constantly communicate with each other, allowing the body to think and act. Serotonin (produced in each individual neuron from
an amino acid called tryptophan) is typically active in the regions of the brain responsible for emotions, sleeping and sensory
During interactions between neurons, serotonin is released from the end of the first
(presynaptic) neuron and picked up by the second (postsynaptic) neuron. Not all of the
serotonin will be taken into the second neuron. The remainder, along with what's released from
the postsynaptic neuron after use, floats within the space between the two -- called the
synaptic cleft -- until enzymes destroy it. Some of the released serotonin is also reabsorbed
by the first neuron.
SSRIs decrease the rate at which the serotonin is taken back into the presynaptic neuron. This
causes more serotonin to linger in the synaptic cleft, also increasing the message's strength as it
passes to the postsynaptic neuron. This leads to a more ideal chemical balance and seems to
have a positive effect on mood. SSRI drugs include Prozac, Paxil, Zoloft and Celexa. For a more
detailed explanation about serotonin and antidepressants, read How Antidepressants Work.
While doctors know that differences in brain and neurotransmitter functions exist, they don't
know whether BDD causes the differences or if the differences cause BDD. However, as
researchers continue to study those discrepancies, they learn valuable information about
specific areas of the brain that might be targeted in BDD treatment.
But researchers are looking beyond biological links, as many cultural and psychological factors
appear to influence BDD. The next section will examine how culture and personal life-events
can determine the way we view ourselves. page 3
Debra Fessett
Although they look normal, people suffering from body dysmorphic disorder
(BDD) perceive themselves as ugly and disfigured. New imaging research reveals
that the brains of people with BDD look normal, but function abnormally when
processing visual details. The UCLA findings are the first to demonstrate a
biological reason for patients' distorted body image.
MRI scans of the brains of BDD patients show predominant activity on the left side of the brain. (Credit:
Image courtesy of University of California - Los Angeles)
Debra Fessett
Debra Fessett
28 years old
26 plastic surgeries
First became a slave to the scalpel after one critical comment from her then husband
Brow lift
Cheek implants
Three nose jobs
Veneers on her teeth
Three lip implants
Two boob jobs
Three breast lifts
Liposuction on her arms,
stomach, hips, thighs, and knees.
“I just moved from a bad relationship with him to a bad
relationship between me and my reflection. After the divorce,
plastic surgery became an obsession for me."
Debra Fessett
Sees self as gruesomely disfigured
 Believes he is not even human
 Despite the fact that everyone else sees a handsome
young man
 Has lost two jobs because of his disorder, spends hours
and hours each day in the bathroom and relies on his
parents to drive him because he finds the rear-view
mirror too distracting to safely drive himself
Debra Fessett
Fearful of peoples' stares makes it hard for her to leave her house.
BDD has cost her many things—a productive life, relationships and, at
moments, her sense of sanity.
"When I look in the mirror I see somebody who is nonhuman. I've had times when I've actually felt physically ill
because I can't understand how a person could look like
this, how God could create somebody that looks like this."
"To hate yourself, to hate who you are—it's difficult beyond
anything I can explain," she says. "Many days I would cry
myself to sleep because all I wanted was to not wake up in
the morning."
Michael Riddle-Crilly
Testing for Body Dysmorphic Disorder
Body Dysmorphic Disorder Exam
 Yale-Brown Obsessive-Compulsive Scale
 Body Satisfaction Scale (BSS)
 Beck Depression Inventory (BDI)
 Beck Anxiety Inventory (BAI)
 Overvalued ideas Scale (OVIS)
Michael Riddle-Crilly
How can we treat BDD?
Cognitive Therapy
Behavior Therapy
Cognitive-Behavioral Therapy
Electroconvulsive Therapy
Neuromodulation (such as Vagal Nerve stimulation and Deep Brain stimulation)
Cosmetic Treatments
Including, but not limited to: Surgery, Dermatological, Dental, and Diets
Michael Riddle-Crilly
Cognitive Behavioral Therapy
Exposure & Response prevention
Attitude Changes
Collecting positive and neutral information about patients’ assumptions that is
normally discounted or distorted to build more realistic assumptions about their body
Encouraging the use of a continuum to rate patients’ ugliness or defectiveness so
that they appear most people in the middle of the continuum.
Reversed role play as described by Newell and Schrubb (1994).
Cognitive Restructuring
CBT can give patients a series of goals so they begin to learn more appropriate
behaviors and develop mechanisms to cope in difficult situations. This method of BDD
therapy is preferred for its effectiveness and relative brevity. When patients adhere to
homework assignments, CBT can help them achieve relief within months.
Michael Riddle-Crilly
Address the goal of treatment
Provide patient with
Basic information on the psychology of physical appearance
The concept of body image
The development of Body Dysmorphic Disorder
Stress that the problem is how the person views themselves from the inside
Therapy is designed to change “body image” and not appearance
Physical appearance is important in interpersonal perception, but mainly in initial impressions
between unacquainted persons
Body image is subjective and psychological and the two variables (body image and physical
appearance) can be independent {e.g., changes in appearance do not always lead to change body
Body image can be altered without having to change ones physical appearance
Self-Monitoring Diary can greatly facilitate cognitive restructuring
Recognize maladaptive behaviors
AVOID arguing with the patient about the reality of the defect
Exposure to avoided situations
Response prevention
Self-management techniques
Exposure PLUS Response prevention
Avoid reassurance
Behavioral self-control
Michael Riddle-Crilly
Cognitive Restructuring
Exposure and Behavioral Experiments
Ritual (Response) Prevention
Perceptual (Mirror) Retraining
Relapse Prevention
Reverse Role-Play
Behavioral experiments or exposure to social situations without their safety behavior
Habit reversal for impulsive behaviors such as skin-picking
Mirror Feedback
Video Feedback
Photo Feedback
Modifying Cognitive Processes
Imagery Rescripting
One author and her colleagues has a 22 weekly session plan, plus 3 “booster” sessions, to treat an
individual with BDD. Optimally, published studies show that they have used 8 to 60 sessions for
Treatment with CBT is typically weekly lasting the traditional hour session (50 minutes), however most
published sessions have used 90 minute sessions.
Individual or group therapy is used depending on the individual
Homework is an essential ingredient of getting better.
Michael Riddle-Crilly
BDD Treatment Algorithm Using
• Confirm BDD Diagnosis
• Comorbid symptoms/
• Family History of Bipolar Disorder
• First treatment
• SRI for 12 weeks, 2-4 weeks at highest tolerated dose recommended by manufacturer
• Second Treatment Decision
• If response see number 5, If no response see number 6
• Maintain
• If sexual side effects occur, add bupropion or sildenafil
• Consider adding buspirone, buprogion, atypical antipsychotic, or clomipramine (check blood levels).
• If no response, consider adding CBT or switch to another SRI.
Michael Riddle-Crilly
Reuptake inhibitor/ Antidepressant
Psychotropic Agent (Neuroleptic)
Mood Stabalizer
Michael Riddle-Crilly
Do you know someone who may be suffering
from Body Dysmorphic Disorder?
Body Dysmorphic Disorder (2010). Definition. Retrieved July 4, 2010 from Mayo Clinic website
Fiori, P. & Giannetti, L.M. (2009). Body Dysmorphic Disorder: A complex and polymorphic affection. Neuropsychiatr
Dis Treat, 5, 477-481. Retrieved July 4, 2010 from PubMed Central website
Geremia, G.M. & Neziroglu, F.. (2001). Cognitive Therapy in the Treatment of Body Dysmorphic Disorder. Clinical
Psychology and Psychotherapy, 8, 243-251.
Gilbert, P. & Miles, J. (2002). Body Shame: Conceptualisation, research, and treatment. New York; Brunner-Routledge.
Neziroglu, F., McKay, D., Todaro, J., & Yaryura-Tobias, J.A. (1996). Effect of Cognitive Behavior Therapy on Persons
With Body Dysmorphic Disorder and Comorbid Axis II Diagnoses. Behavior Therapy, 27, 67-77.
Neziroglu, F.A. & Yaryura-Tobias, J.A. (1993). Exposure, response Prevention, and Cognitive Therapy in the Treatment of
Body Dysmorphic Disorder. Behavior Therapy, 24, 431-438
Phillips, K.A. (2009). Understanding Body Dysmorphic Disorder: An essential guide. New York; Oxford University Press.
Rosen, A.C. (1995). The Nature of Body Dysmorphic Disorder and Treatment With Cognitive Behavior Therapy. Cognitive
and Behavioral Therapy Practice, 2, 143-166.
Toothman, J. (2010). How Body Dysmorphic Works. Retrieved June 20, 2010 from Discovery Health website:
Veale, D., Gournay K., Dryden, W., Boocock, A., Shah, F., Willson, R., & Walburn, J. (1996). Body Dysmorphic Disorder:
A Cognitive Behavioural model and Pilot Randomised Controlled Trial. Behav. Res. Ther., 34 (9), 717-729.
Veale, D. & Neziroglu. F. (2010). Body Dysmorphic Disorder. Malden, MA; Wiley-Blackwell.
Veale, D. & Riley, S. (2001). Mirror, Mirror on the wall, who is the ugliest of them all? The psychopathology of mirror
gazing in body dysmorphic disorder. Behaviour Research and Therapy, 39, 1381-1393.
Treatment and
Research Programs
BDD and Body Image Program
Providence, RI
BDD Clinic and Research Unit
Boston, MA
Compulsive, Impulsive, and Anxiety Disorders Program
New York, NY
Los Angeles Body Dysmorphic Disorder & Body Image Clinic
Los Angeles, CA
UCLA Body Dysmorphic Disorder Research Program
Los Angeles, CA
UCLA OCD Intensive Treatment Program
Los Angeles, CA
University of California San Diego OCD Program
La Jolla, CA
Menninger Clinic OCD Treatment Program
Houston, TX
BDD Treatment Programme
Centre for Anxiety Disorders & Trauma
Bio-Behavioral Institute
Massachusetts General Hospital/ McLean Hospital OCD Institute at McLean Hospital
Rogers Memorial Hospital OCD Center - Oconomowoc
Rogers Memorial Hospital - Milwaukee
Southgate, London, UK
London, UK
Great Neck, NY
Belmont, MA
Oconomowoc, WI
Milwaukee, WI
Organizations & Websites
Books & Other Readings
BDD Central –
Obsessive Compulsive Foundation –
Association for Behavioral and Cognitive Therapists –
OCD Action –
National Alliance on Mental Illness –
The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder, Revised and Expanded Edition
(Katherine A. Phillips, M.D.)
Cognitive-Behavioral Therapy for Body Dysmorphic Disorder
(Sabine Wilhelm, Ph.D., Katherine A. Phillips, M.D., and Gail Steketee, Ph.D.)
The Adonis Complex: How to Identify, Treat, and Prevent Body Obsession in Men and Boys
(Harrison G. Pope, Jr. M.D., Katherine A. Phillips, M.D., and Roberto Olivardia, Ph.D.)
Feeling Good About the Way You Look
(Sabine Wilhelm, Ph.D.)
Body Dysmorphic Disorder
(David Veale and Fugen Neziroglu)
Scientific research articles published in journals