Download the fatal addiction to plastic surgery

Anxiety Disorders Association of America
30th Annual Conference
2010
THE FATAL ADDICTION TO PLASTIC
SURGERY
Diagnosing and Treating BDD
Successfully for a Lifetime
Westwood Institute for Anxiety Disorders, Inc.
PRESENTER:
¾ Eda Gorbis, Ph.D., LMFT
Founder/Director of the Westwood Institute for Anxiety Disorders, Inc.
Assistant Clinical Professor at the UCLA Department of Psychiatry
Westwood Institute for Anxiety Disorders, Inc.
921 Westwood Blvd., Suite 224, Los Angeles, CA 90024
Tel: (310) 443-0031, Ext. #2
Fax: (310) 443-1553
Email: [email protected]
www.hope4ocd.com
Dr. Gorbis joined Dr. Edna B. Foa, an internationally recognized authority who
pioneered the protocols for ERP, in 1994 and received extensive training in the field
of OCD treatment. In 1996, she began working with Dr. Schwartz at UCLA, where
she integrated Dr. Foa’s ERP methods. Over the past seven years, she has treated
more than 150 in- and out-patients with OCD while working closely with their
families. Her method synthesizes the blends successful treatment modalities for
OCD and PTSD and has yielded a high rate of success. Dr. Gorbis’ work has
received large amount of attention from the national media. Her intensive method
has been the topic on National Geographic, the Discovery Channel, BBC, 20/20,
MTV, and numerous local news channels.
© 2010 Westwood Institute for Anxiety Disorders, Inc.
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Patients with Body Dysmorphic Disorder
Body Dysmorphic Disorder (BDD) is a disabling condition that until recently has been
largely ignored. However, it has been estimated that 1 to 2 percent of the general
population has BDD, which is nearly 5 million people in the United States alone. BDD is
aptly described as the disease of “imagined ugliness.” Most of us pay attention to our
appearance but BDD sufferers worry excessively and unreasonably about some
aspects of their appearance. They may be concerned that their nose is too big, chin
misshapen, eyelids too puffy, breasts too small, hips too large, etc. If their facial pores
are visible, they obsess that they have facial scarring. Any blemish such as acne,
freckles or anything else becomes a focal point constantly drawing their attention and
thoughts. These flaws may be non-existent or minimal but you cannot reassure a BDD
victim. BDD patients may compulsively remove their skin, attempt self surgeries and
even amputations in extreme cases. These obsessive concerns cause significant
emotional distress (e.g. depression) and often significantly interfere with functioning.
Yet, most BDD patients do not seek psychiatric /psychological help. Their disease
dictates the course of action and those who opt for non-psychiatric treatment will
undergo unnecessary plastic surgeries and undertake life-threatening procedures. A
method of externalizing internal impulses through the use of distorted images produced
by using crooked mirrors is a new approach to the treatment of BDD.
© 2010 Westwood Institute for Anxiety Disorders, Inc.
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EDUCATIONAL OBJECTIVES:
I.
What is BDD?
1) Prevalence & Epidemiology
2) Obsessive Concerns
3) Compulsive Procedures
4) DSM-IV Criterion
II. When Body Image Dissatisfaction Becomes a Disorder.
1) Definition of the Ideal Body
a. Culturally
b. Time Period
2) Concerns with Appearance
a. Interference with Functioning
b. Preoccupation to Pathology
III. The Elusive Remedy or the Sign of a Disease?
1) Pervasiveness of the Disease
a. Effects all areas of life
2) Medical Procedures
a. Cosmetic Surgery
b. Dermatological Treatment
3) Satisfaction with Medical Treatments
a. Plastic surgery provides no benefit
b. BDD patients continue to be dissatisfied
4) Emotional Effects
a. Guilt
b. Anger
IV. BDD Treatment Challenges
1) Currently Available Treatments
a. Cognitive-Behavioral Therapy (CBT)
b. Medication
2) Acceptance of a Psychological Disorder
a. Greatest challenge
b. Typically for pharmacological treatments
3) Targeting Specific Symptoms
a. Insight Deficiency
b. Distress & Anxiety
c. Fears
d. Rituals
e. Resizing the defect
f. Body Image Distortion
4) Treatment Efficacy
a. Requires individually tailored treatments
© 2010 Westwood Institute for Anxiety Disorders, Inc.
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5) Comorbidity
a. OCD/OC Spectrum Disorders
b. Major Depression
c. Social Phobia
V. “Crooked Mirrors”: A New Treatment Method.
1) Distorted Crooked Mirrors
a. Highly reflective aluminum surfaces that can bend in different directions.
b. Inexpensive
c. Easily concealed behind curtains
d. Occupy little space
2) Externalization Therapy
a. Gradual Exposure & Response Prevention
b. Internal Irrational Stimuli.
c. Internalized Misperception
d. Hierarchical Order
3) Duration of Treatment
a. 15 90-minute sessions
4) Efficacy
a. 6 out of 7 patients improved significantly
b. 1 patient failed to demonstrate treatment gains
5) Case Vignette
a. 45-year old female
b. 17 plastic surgeries
c. Demoralized
d. Pretreatment Y-BOCS = 32
e. Post-Treatment Y-BOCS = 10
f. 5-year follow-up: no further surgeries
© 2010 Westwood Institute for Anxiety Disorders, Inc.
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© 2010 Westwood Institute for Anxiety Disorders, Inc.
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Body Dysmorphic Disorder Modification of the Y-BOCS
(BDD-YBOCS)
For each item, circle the number identifying the response that best characterizes
the patient during the past week.
1. Time occupied by thoughts
about body defect
How much of your time is occupied by THOUGHTS
(not including associated behaviors) about a defect or
flaw in your appearance (such as your face, nose, hair,
skin, breasts, genitals, hands?)
2. Interference due to thoughts
thoughts about body defects
How much do your THOUGHTS about your body
defect(s) interfere with your social or work (role)
functioning? Is there anything you aren’t doing or
can’t do because of them?
3. Distress associated with
thoughts about body defect
How much distress do your THOUGHTS about
your body defect(s) cause you? (Rate “disturbing”
feelings or anxiety that seem to be triggered by
these thoughts, not general anxiety or anxiety
associated with other symptoms.)
4. Resistance against thoughts
of body defect
How much of an effort do you make to resist these
THOUGHTS? How often do you try to disregard
them or turn your attention away from these thoughts
as they enter your mind? (Only rate effort made to
resist, NOT success or failure in actually controlling
the thoughts. How much patient resists may or may not
correlate with ability to control them.)
0 = None
1 = Mild (less than 1 hr/day).
2 = Moderate (1-3 hrs/day).
3 = Severe (3-8 hrs/day).
4 = Extreme (greater than 8 hrs/day).
0 = None.
1 = Mild, slight interference with social or
occupational activities, but overall
performance not impaired.
2 = Moderate, definite interference with
social or occupational performance,
but still manageable.
3 = Severe, causes substantial impairment
in social or occupational performance.
4 = Extreme, incapacitating.
0 = None.
1 = Mild, and not too disturbing.
2 = Moderate and disturbing but still
manageable.
3 = Severe and very disturbing.
4 = Extreme and disabling distress.
0 = Makes an effort to always resist,
or symptoms so minimal doesn’t
need to actively resist.
1 = Tries to resist most of time.
2 = Makes some effort to resist.
3 = Yields to all such thoughts without
attempting to control them but yields
with some reluctance.
4 = Completely and willingly yields to
all such thoughts.
© 2010 Westwood Institute for Anxiety Disorders, Inc.
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5. Degree of control over thoughts
about body defect
How much control do you have over your THOUGHTS
about your body defect(s)?
How successful are you in stopping or diverting these
thoughts?
6. Time spent in activities related
to body defect
How much time do you spend in ACTIVITIES related
to your concern over your appearance or a body defect,
(such as, but not limited to, mirror checking, trying to
conceal the defect, or consulting plastic surgeons or
dermatologists or undergoing surgical procedures to
correct the defect)?
0 = Complete control, or no need for control
because thoughts are so minimal.
1 = Much control, usually able to stop or
divert these thoughts with some effort
and concentration.
2 = Moderate control, sometimes able to
stop or divert these thoughts.
3 = Little control, rarely successful in
stopping thoughts, can only divert
attention with difficulty.
4 = No control, experienced as completely
involuntary, rarely able to even
momentarily divert attention.
0 = None.
1 = Mild (spends less than 1 hr/day).
2 = Moderate (1-3 hrs/day).
3 = Severe (spends 3-8 hrs/day).
4 = Extreme (spends more than 8 hrs/day in
these activities).
Read list of activities (check all that apply)
1. checking mirrors/other surfaces
2. rearranging/selecting clothing
3. grooming activities
4. applying makeup
5. camouflaging with clothes and other things
6. scrutinizing other’s appearance/comparing
7. questioning others about your appearance
8. skin picking
9. touching
10. other
7. Interference due to activities related
to the body defect
How much do the above ACTIVITIES interfere with
your social or work (role) functioning?
Is there anything you don’t do because of them?
0 = None.
1 = Mild, slight interference with social or
occupational activities, but overall
performance not impaired.
2 = Moderate, definite interference with
social or occupational performance,
but still manageable.
3 = Severe, causes substantial impairment
in social or occupational performance.
4 = Extreme, incapacitating.
© 2010 Westwood Institute for Anxiety Disorders, Inc.
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8. Distress associated with behaviors
related to body defect
How would your feel if prevented from performing
these ACTIVITIES?
[Pause]
How anxious would you become?
9. Resistance against compulsions
How much of an effort do you make to resist these
ACTIVITIES? (How much the patient resists these
behaviors may not correlate with his/her ability to
control them.)
10. Degree of control over compulsive
behaviors
0 = None.
1 = Mild, only slightly anxious if behavior
prevented, or only slight anxiety during
the behavior.
2 = Moderate, reports that anxiety would
mount but remain manageable if
behavior is prevented or that anxiety
increases but remains manageable during
such behavior.
3 = Severe, prominent and very disturbing
increase in anxiety if behavior is
interrupted, or prominent and very
disturbing increase in anxiety during the
behavior.
4 = Extreme, incapacitating anxiety from
any intervention aimed at modifying
activity, or incapacitating anxiety
develops during behavior related to body
defect.
0 = Makes an effort to always resist, or
symptoms so minimal doesn’t need to
actively resist.
1 = Tries to resist most of the time.
2 = Make some effort to resist.
3 = Yields to almost all of these behaviors
without attempting to control them, but
does so with some reluctance.
4 = Completely and willingly yields to all
behaviors related to body defect.
0 = Complete control, or control is
because symptoms are mild.
1 = Much control, experiences pressure to
How strong is the drive to perform the behaviors?
Perform the behavior, but usually able to
exercise voluntary control over it.
[Pause]
2 = Moderate control, strong pressure to
perform behavior, can control it only
How much control do you have over them?
with difficulty.
3 = Little control, very strong drive to
to perform behavior, must be carried to
completion, can delay only with
difficulty.
4 = No control, drive to perform behavior
experienced as completely involuntary
and overpowering, rarely able to even
momentarily delay activity.
© 2010 Westwood Institute for Anxiety Disorders, Inc.
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11. Insight
Is it possible that your defect might be less
noticeable or less ugly than you think it is?
How convinced are you that (body part) is as
unattractive as you think it is?
Can anyone convince you that it doesn’t
look so bad?
12. Avoidance
Have you been avoiding doing anything, going
any place, or being with anyone because of your
thoughts or behaviors related to your body defect?
(if YES, then ask: How much do you avoid? Rate
degree to which patient deliberately tries to avoid
things.)
0 = Excellent insight, fully rational.
1 = Good insight. Readily acknowledges
absurdity or unreasonableness of
thoughts or behaviors but does not seem
completely convinced that there isn’t
something besides anxiety to be
concerned about.
2 = Fair insight. Reluctantly admits that
thoughts or behavior seem unreasonable
but wavers.
3 = Poor insight. Maintains that thoughts or
behaviors are not reasonable.
4 = Lacks insight, delusional. Definitely
convinced that concerns and behavior
are reasonable, unresponsive to contrary
evidence.
0 = No deliberate avoidances.
1 = Mild, minimal avoidance.
2 = Moderate, some avoidance clearly
present.
3 = Severe, much avoidance; avoidance
prominent.
4 = Extreme, very extensive avoidance;
patient avoids almost all activities.
almost all activities.
Total BDD-YBOCS Score: ________
© 2010 Westwood Institute for Anxiety Disorders, Inc.
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