Treatment with Cognitive Therapy

1. Somatoform Disorder 300.7 Treatment with Cognitive Therapy July 19, 2010 PSYU 575: Advanced Individual Counseling Brandman University Instructor: Dr. SauleBuzaite, PhD, LMFT Presented By: Jackie Camarena Michael Crilly Debra Fessett

2. 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.” • EnricoMorselli 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 steroids Jackie Camarena

3. Research • 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 development. • 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 disorders. • 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

4. 1 minute 33 seconds to 2 minutes 10 seconds CSI - The Hunger Artist Part 1 • http://www.youtube.com/watch?v=0HfFxg3Dllg&feature=related

5. BDD • How is Body Dysmorphic Disorder defined? • Diagnostic Criteria • Criterion 1: Preoccupation • Criterion 2: Distress or Impairment of Functioning • Criterion 3: Differentiating BDD from Other Disorders Jackie Camarena

6. 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 functioning. 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

7. Criterion 2: Distress or Impairment in Functioning 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 parent). Partially or completely avoid many of these situations: Friendships (ability to have friends) Spending time with friends Dating 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

8. Criterion 3: Differentiating BDD from other Disorders Anorexia Nervosa Gender Identity Disorder Major Depressive Episode Social Phobia Obsessive-Compulsive Disorder Schizophrenia Jackie Camarena

9. 5 minutes 40 seconds to 8 minutes 7 seconds CSI - The Hunger Artist Part 4 • http://www.youtube.com/watch?v=GHuyw9BKwaA&feature=related

10. Differentials Normal concern about appearance Eating Disorder Anorexia Nervosa Bulimia Nervosa Gender Identity Disorder Major Depressive Episode Avoidant Personality Disorder Social Phobia Obsessive-Compulsive Disorder Trichotillomania Delusional Disorder, Somatic Type Koro Culture related syndrome occurring primarily in Southeast Asia that may be related to BDD Jackie Camarena

11. Co-Morbid Disorders • Major Depressive Disorder • Obsessive-Compulsive Disorder • Anxiety disorders, especially social phobias • Eating Disorders Jackie Camarena

12. 1 minute 25 seconds to 3 minutes 15 seconds CSI – The Hunger Artist Part 5 • http://www.youtube.com/watch?v=tPqN5137TIA&feature=related

13. Causes of BDD Largely Unstudied Genetic & Neurobiological Risk factors Psychological Risk Factors Social & Cultural Risk Factors Triggering Events Debra Fessett

14. BDD Symptoms Causes of BDD Debra Fessett

15. http://health.howstuffworks.com/body-dysmorphic-disorder.htm/printable page 3 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 perception . 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. Debra Fessett

16. 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) 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. Debra Fessett

17. Debra Fessett

18. JENNY 28 years old 26 plastic surgeries First became a slave to the scalpel after one critical comment from her then husbandBrow lift Botox 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. $80,000.00 “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

19. Jesse • 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

20. Taryn 24-year-old 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 non-human. 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

21. Testing for Body Dysmorphic Disorder • Body Dysmorphic Disorder Exam (BDDE) • Yale-Brown Obsessive-Compulsive Scale for BDD (YBOCS-BDD) • Body Satisfaction Scale (BSS) • Beck Depression Inventory (BDI) • Beck Anxiety Inventory (BAI) • Overvalued ideas Scale (OVIS) Michael Riddle-Crilly

22. How can we treat BDD? • POSITIVE TREATMENTS: • Cognitive Therapy • Behavior Therapy • Cognitive-Behavioral Therapy • Medication • Electroconvulsive Therapy • Neurosurgery • Neuromodulation (such as Vagal Nerve stimulation and Deep Brain stimulation) • NEGATIVE TREATMENTS • Cosmetic Treatments • Including, but not limited to: Surgery, Dermatological, Dental, and Diets Michael Riddle-Crilly

23. 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

24. CBT 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 image} 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 BEHAVIORAL PROCEDURES Exposure to avoided situations Response prevention Self-management techniques Exposure PLUS Response prevention Avoid reassurance Behavioral self-control Michael Riddle-Crilly

25. CBT • 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. • 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

26. BDD Treatment Algorithm Using Medications Michael Riddle-Crilly

27. Psychopharmacological FluvoramineClomipramineDesipramineCitalopramAntidepressant VenlafaxineBupropion Antidepressant Escitalopram Reuptake inhibitor/ Antidepressant BusiproneAntianxiety Levetiracetam Antiepileptic OlanzapineZiprasidoneResperidone Psychotropic Agent (Neuroleptic) Lithium Mood Stabalizer Methylphenidate Stimulant Michael Riddle-Crilly

28. Do you know someone who may be suffering from Body Dysmorphic Disorder?

29. References • Body Dysmorphic Disorder (2010). Definition. Retrieved July 4, 2010 from Mayo Clinic website http://www.mayoclinic.com/health/body-dysmorphic-disorder/DS00559 • Fiori, P. & Giannetti, L.M. (2009). Body Dysmorphic Disorder: A complex and polymorphic affection. NeuropsychiatrDis Treat, 5, 477-481. Retrieved July 4, 2010 from PubMed Central website http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2747387/ • 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: http://health.howstuffworks.com/mental-health/mental-disorders/body-dysmorphic-disorder.htm • 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.

30. 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 Southgate, London, UK • Centre for Anxiety Disorders & Trauma London, UK • Bio-Behavioral Institute Great Neck, NY • Massachusetts General Hospital/ McLean Hospital OCD Institute at McLean Hospital Belmont, MA • Rogers Memorial Hospital OCD Center - Oconomowoc Oconomowoc, WI • Rogers Memorial Hospital - Milwaukee Milwaukee, WI

31. Organizations & WebsitesBooks & Other Readings • BDD Central – www.bddcentral.com • Obsessive Compulsive Foundation – www.ocfoundation.org • Association for Behavioral and Cognitive Therapists – www.aabt.org • OCD Action – www.ocdaction.org.uk • National Alliance on Mental Illness – www.nami.org • 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 FugenNeziroglu) • Scientific research articles published in journals