Facts about Body dysmorphic disorder

We have found most of this material by seeking on the internet or in newspapers. The copyrights and responsability of the content of this material rests by the owners. We have used this information only for educational purposes. The material on this server may not be reproduced without permission of the original owners. If you are owner of the proposed material and you find it inconvenient to find your material on this site, please give a sign and we will immediatelly remove the information from this site. If you don't have problems with it, we will thank you for your interest and kindness. Gerard.Gielen@saw.khlim.be

Bron : http://kidshealth.org/PageManager.jsp?dn=KidsHealth&lic=1&ps=107&cat_id=145&article_set=22572

Body Dysmorphic Disorder

To your dismay, your daughter has started to complain more and more about the appearance of her eyelids. She grudgingly compares them to those of her classmates. You frequently catch her standing before a mirror, scrutinizing their appearance. When you try to discuss your concerns, she becomes defensive. To make matters worse, you've observed her reading materials about cosmetic surgery.

How do you know if your daughter is simply experiencing a typical stage in adolescence or if she has a more complex problem? Teens seem to worry incessantly about their weight and appearance, but some may become obsessed with a specific flaw or perceived defect. Along with eating disorders, body dysmorphic disorder (BDD) has become a growing concern for young adults.

The severity of this disorder varies. Some are able to function and cope with daily life, whereas others experience paralyzing symptoms of depression, anxiety, and avoidance of social situations.

"These adolescents have a very distorted view of how they look, and it does not match how other youth see them," says Katharine Phillips, MD, director of the Body Image Program at Butler Hospital in Providence, Rhode Island.

What Is BDD?
Those who have BDD are abnormally preoccupied with a real or imagined defect in their physical appearance. For example, they may worry endlessly that their skin is pale, their hair is too curly, their nose is too long, or something else is wrong with the way they look. When others tell them they look fine or that the flaw isn't noticeable, people with this disorder don't hear or believe it. The person with BDD may also experience periods of depression, anxiety, and even suicidal thoughts because of their preoccupation with their perceived flaw.

"Body dysmorphic disorder is a type of anxiety disorder. The disorder is different from eating disorders because it involves other factors besides one's weight or body size. Physical features or attributes are what provokes the person's anxiety and negative beliefs. Those with BDD have several 'cognitive distortions' about how they look. Cognitive distortions are distorted beliefs about a perceived flaw," explains Steven Pittman, PhD, a licensed clinical psychologist.

What Causes BDD?
BDD is thought to be associated with a chemical imbalance in the brain, which may be genetically based.

"A child who has a family with a history of generalized anxiety disorder or obsessive-compulsive disorder is more prone to developing this type of problem. Also, those coming from a family with an upward socioeconomic status seem to be more at risk for developing this disorder. I have also seen a trend in families that have unrealistically high expectations," Dr. Pittman says.

Signs and Symptoms of BDD
There are many ways to determine if your child is at risk for developing this disorder, or if she is already dealing with it. Dr. Phillips offers these clues:

frequently comparing the appearance of the perceived defect with that of others
frequently checking appearance of the specific body part in mirrors and other reflective surfaces
camouflaging the perceived defect with clothing, makeup, hats, hands, or posture
seeking surgery, dermatological treatment, or other medical treatment when doctors or other people have said that the flaws are minimal or nonexistent or that such treatment isn't necessary
seeking reassurance about the flaw or attempting to convince others of its ugliness
excessive grooming (for example, combing hair, shaving, removing or cutting hair, applying makeup)
avoiding mirrors
frequently touching the perceived defect
picking one's skin
measuring the disliked body part
excessively reading about the defective body part
avoiding social situations in which the perceived defect might be exposed
feeling anxious and self-conscious around other people because of the perceived defect
Signs of BDD are often evident in a child's late teen years or early adulthood, but certain behaviors or other signs may be noticed earlier.

Diagnosing BDD
BDD seems to affect males and females equally. A person whose family has a high incidence of mood disorders and obsessive-compulsive disorders also seems to be at high risk. According to the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL - FOURTH EDITION (DSM-IV), doctors use the following criteria to diagnose BDD:

preoccupation with the perceived physical defect
clinically significant distress or impairment in school, work, or social situations
preoccupation is not better explained by another mental disorder, such as anorexia nervosa
Treating BDD
"Therapy and medication are the primary means of treatment of this disorder. Antidepressants such as sertaline and fluoxetine and others are used in conjunction with psychotherapy. Often, the medication may not cure the disorder, but it makes the person more amenable to therapy and hopefully more open to receiving ongoing treatment," Dr. Pittman says.

Katharine Phillips concurs: "The prescription-only SSRIs [selective serotonin reuptake inhibitors such as sertaline and fluoxetine] are not addictive and are usually well tolerated. They can significantly relieve BDD symptoms by diminishing bodily preoccupation, distress, depression, and anxiety and by significantly allowing increased control over the youth's thoughts and improving functioning. In some cases, these medications are lifesaving, especially for those who have attempted suicide in their despair over their appearance."

Cognitive-behavioral therapy may also be helpful. In this therapy, a therapist helps the person with BDD resist compulsive behaviors, such as mirror checking. It's important to determine whether a therapist has been specifically trained in cognitive-behavioral therapy because many other types of therapy do not appear to be effective in the treatment of BDD.

Helping Your Child Develop a Positive Self-Image
As a parent, you can help your child maintain a positive self-image and self-esteem. Here are some ways you can help:

Always maintain an open door policy when it comes to problem solving. If your child knows it's OK to approach you with problems or concerns, she's more likely to do so.
Be aware of peer influence and the affects of media on your child. Is your child reading too many fashion magazines or spending time with a new crowd?
Recognize the need for professional help. If you suspect your child has BDD, a doctor or professional therapist can help.
Know the signs and symptoms of suicidal behavior. If you think your child is suicidal, get help immediately. Your child's doctor can refer you to a psychologist or psychiatrist, or you can contact your local hospital's department of psychiatry and ask for a referral. Your community mental health association or county medical society can also provide referrals.
Reviewed by: Paul Robins, PhD
Date reviewed: June 2000

Bron : http://www.healthyplace.com/Communities/Eating_Disorders/peacelovehope/bdd.html


No matter how much weight is lost, or no matter how much food is thrown up, the person with anorexia or bulimia will constantly see the same overweight, vile, failure in the mirror. This typically leads to very destructive and even deadly methods of weight loss in a desperate attempt to lose the distorted perception - in this case, fat (failure). It is very hard, though, for anyone that does not have an eating disorder to be able to understand just how someone could do this to themselves - go through hospitilizations and near death experiences even - but continually see themselves so distorted. Even though Body Dysmorphic disorder isn't just shown in cases of eating disorders (someone afflicted with BDD can obsess not about weight, but instead about their hair, nose, chest, etc.), it still hurts and ruins the lives of whoever is afflicted with it.


At one time or another we all worry about our appearance, but when you wake up degrading your nose, hair, chest, WEIGHT, etc. and then continuing to have these thoughts all day, that's when there is a problem. Closely linked to other disorders and psychiatric conditions, Body Dysmorphic Disorder (termed shortly BDD) is a serious disorder that is growing fast. People that suffer from BDD not only dislike some aspect of how they look, they're preoccupied severely with it. Most get to the point where it is very hard to go outside or sit down comfortably, or go to work and talk to others, without thinking the self-degrading thoughts about their flaws. The thoughts soon over take the person's mind and it is all he/she can think about.

The problem, though, is that all of these self-degrading thoughts about a perceived flaw are distorted. Many, many times the supposed flaw doesn't even exist, or an "imperfect" body part is blown entirely out of proportion. However, the person themselves cannot see that what they believe is distorted. Many hold the belief that they are seeing all of this, therefore it MUST be true. This is one of the main reasons that it is so hard for people on the "outside" to try and convince even the most severely emaciated people with anorexia that they are not fat or failures - the people with anorexia and/or bulimia themselves literally cannot look in the mirror and see the same person that everyone else sees.


Kinda like a cloud i was up way up in the sky
and i was feeling some feelings you wouldn't believe
Sometimes i don't believe them myself
and i decided i was never coming down
Just then a tiny little dot caught my eye
It was just about too small to see
but i watched it way too long
...and that dot was pulling me down-NIN

It's estimated that Body Dysmorphic Disorder affects 1 in 50 people, mostly teenagers and 20-somethings with either a gradual or abrupt onset. Often the person is a perfectionist, like most people with eating disorders. Nothing is good enough because the person cannot see that what they have done is absolutely fine, or that they are on the border of near death (in the case of anorexia and extreme weight loss). Low self-esteem is a trademark of those with BDD as they feel like colossal failures for their perceived physical flaws.


BDD can lead or take after other psychiatric problems as well. Depression, obsessive compulsive disorder, eating disorders, anxiety issues, agoraphobia, and trichotillomania (hair pulling) are all problems that commonly follow or trigger BDD.

One person that I know that is in treatment for BDD and other issues became afflicted after a rape. Although she doesn't fit the common statistics in that she is 32 and Latino, the BDD immediately showed itself after the incident. She felt that the rapist was "inside of her" somehow and making her "ugly and disgustingly horrid from the inside out." She began to check her face and nude body in the mirror. At her worse, she was doing this about 5 hours a day. She felt degraded and disgusting from what happened to her, believing that only something that was disgusting and worthless and ugly could be raped. Eventually, the isolation and weird habits pushed her family to convince her to get help (thankfully). It took a lot of persistence, though, since she did not believe there was a problem, even in her most severely depressed times.


Often Body Dysmorphic Disorder is mis-diagnosed because doctors tend to have a lack of familiarity with the disorder. Many times those afflicted feel so ashamed and worthless that they down-play the problem or do not even recognize that they need help, so they end up staying in hiding. Families may even trivialize this problem, not realizing that this extreme distortion cannot be resolved through "getting over it" or calling it a "phase." However, when you or someone you know is ready to accept help and is willing to get it, there are therapists out there that specialize in treating distortion cases while new methods of treatment for Body Dysmorphic Disorder are currently being studied.

One recent study was made where 17 individuals, all diagnosed with BDD, spent 4 weeks of daily 90 minute sessions with therapists. Cognitive behavior therapy was used to treat their conditions. Further treatment for Body Dysmorphic Disorder included having them exposed to their perceived physical defect, and they were prevented from engaging in any behaviors that increased the discomfort and triggered the BDD more. In the cognitive behavior therapy the individuals were also taught how to resist compulsive behaviors and face avoided situations. At the end of this study, a significant decrease was found in the individuals' pre-occupations and time spent engaged in destructive behaviors and thoughts.

Common anti-depressants were also used to help further the treatment. Prozac, Zoloft, Paxil, Luvox, and Anafranil are all common anti-depressants that are used to treat this disorder (as well as depression), and they have all been show to help stop the behaviors associated with Body Dysmorphic Disorder.

Bron : http://www.ncpamd.com/body_dysmorphic_disorder.htm

Body Dysmorphic Disorder, (BDD) is listed in the DSM-IV under somatization disorders, but clinically, it seems to have similarities to Obsessive-Compulsive Disorder (OCD).

BDD is a preoccupation with an imagined physical defect in appearance or a vastly exaggerated concern about a minimal defect. The preoccupation must cause significant impairment in the individual’s life. The individual thinks about his or her defect for at least an hour per day.

The individual’s obsessive concern most often is concerned with facial features, hair or odor. The disorder often begins in adolescence, becomes chronic and leads to a great deal of internal suffering.

The person may fear ridicule in social situations, and may consult many dermatologists or plastic surgeons and undergo painful or risky procedures to try to change the perceived defect. The medical procedures rarely produce relief. Indeed they often lead to a worsening of symptoms. BDD may limit friendships. Obsessive ruminations about appearance may make it difficult to concentrate on schoolwork.

Other behaviors that may be associated with BDD

Frequent glancing in reflective surfaces
Skin picking
Avoiding mirrors
Repeatedly measuring or palpating the defect
Repeated requests for reassurance about the defect.
Elaborate grooming rituals.
Camouflaging some aspect of one’s appearance with one’s hand, a hat, or makeup.
Repeated touching of the defect
Avoiding social situations where the defect might be seen by others.
Anxiety when with other people.
BDD tends to be chronic and can lead to social isolation, school dropout major depression, unnecessary surgery and even suicide.

It is often associated with social phobia and OCD, and delusional disorder. Chronic BDD can lead to major depressive disorder. If it is associated with delusions, it is reclassified as Delusional disorder, somatic subtype. Bromosis (excessive concerns about body odor) or Parasitosis (concern that one is infested by parasites) can classically be associated with delusions.

Other conditions that might be confused with BDD: Neglect caused by a parietal lobe brain lesion; anorexia nervosa, gender identity disorder.

Milder body image disturbances that do not meet criteria for BDD. :

Benign dissatisfaction with one’s looks. This does not affect the person’s quality of life. 30-40% of Americans may have these feelings.
Moderate disturbance with one’s body image. The person’s concerns about appearance cause some intermittent anxiety or depression.
Treatment: It is at times difficult to get an individual with BDD into psychiatric treatment because he or she may insist that the disorder has a physical origin. We prefer that the referring physician call us in advance so that we can strategize on how best to encourage the individual to accept help. Treatment often involves the use of SSRI medications (such as sertraline or fluoxetine) and cognitive-behavioral psychotherapy. In this type of psychotherapy the therapist helps the affected individual resist the compulsions associated with the BDD such as repeatedly looking in mirrors or excessive grooming (response prevention) If the individual avoids certain situations because of fear of ridicule, he or she should be encouraged to gradually and progressively face feared situations. If the individual plans to seek invasive medical/surgical treatment, the therapist should attempt to dissuade the patient or ask permission to talk with the surgeon. The therapist helps the individual to understand how some of his or her thoughts and perceptions are distorted and helps the patient replace these perceptions with more realistic ones. Family behavioral treatment can be useful, especially if the affected individual is an adolescent. Support groups if available, can help.

For more information, read The Broken Mirror or Learning to Live with Body Dysmorphic Disorder by Katharine Phillips, M.D.

Bron : http://www.brown.edu/Administration/George_Street_Journal/v22/v22n5/dysmorph.html


When minor flaws loom large in the mirror


Professor leads way in recognizing, treating body dysmorphic disorder


By Kristen Lans
With her long strawberry-blond hair, large green eyes and beautiful complexion, 22-year-old Jennifer would be considered attractive by any standards.

She reminded Katharine A. Phillips of the captain of a high school cheerleading squad, but there had been no crisp fall afternoons on the sidelines of the football field for Jennifer: She had dropped out of high school, and was steadily dropping out of public life.

"I'm too scared to go out - everyone will see how ugly I am," Jennifer told Phillips, the assistant professor of psychiatry who diagnosed the young woman with body dysmorphic disorder (BDD).

Phillips, director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital, is one of the nation's foremost experts of BDD, in which sufferers are obsessed with perceived flaws in their appearance to the extent that it disrupts their life, and at its extreme can lead to thoughts of suicide.

Jennifer purchased clothes through catalogs, went to the food store during the middle of the night, and rarely ventured out of her parents' home during the day because she believed her skin was pimpled and scarred, Phillips wrote in her book on the disorder, "The Broken Mirror."

Once Jennifer tried to go to the store during the day, but got stuck in a traffic jam. Panicking that the other drivers were staring at her, she abandoned the car and ran to the seclusion of a telephone booth to call her mother.

"Their suffering can be so intense," said Phillips." It is clear that it is not under their control ... you just can't will yourself to stop."

In Jennifer's words: "I try not to think about it, but I have to. I think about it for most of the day. It's the first thing I think of when I wake up."

Men as well as women are diagnosed with BDD, said Phillips. Most are in their 30s and worry about their appearance up to three hours a day. Their most common obsessions concern their skin, hair and nose.

Phillips began seeing patients with symptoms of BDD as a resident at the McLane Hospital in Belmont, Mass., but she had barely any knowledge on the disorder. There were never any lectures on BDD in either medical school or residency, she said.

"I just listened to my patients. Some people came in and were extremely distraught," said Phillips. "I thought it was astounding, yet it was generally unknown ... somehow it had fallen through the cracks of our knowledge."

Once Phillips began researching the disorder, she discovered case descriptions from well-known psychiatrists going back 100 years that were remarkably consistent with the patients she was treating.

An estimated 2 percent of the population is afflicted with BDD, and Phillips said she has seen some 300 patients with the disorder. They include some as young as a 6-year-old boy who believed his teeth were yellow, his stomach was "fat," and his hair looked wrong. None of his "defects" were discernible to others.

He would brush his hair for nearly an hour each morning, and if he could not get it to look "right" he would dunk his head in water and restart his grooming routine, often causing him to be late for school, according to Phillips.

When the boy first arrived in a psychiatrist's office at Butler, he crouched to look at his reflection in the chrome on the chair, she said.

That boy, as well as some other patients, have responded well to treatment with a number of antidepressants, said Phillips. Cognitive behavioral therapy also has been a successful treatment, she said.

However, cautioned Phillips, "It is new territory - we are still very early in the research on BDD."

BDD sufferers may eventually find relief through treatment that makes Phillips' research crucial, said former colleague David Guevremont.

"It's extremely valuable," said Guevremont, of the Blackstone Valley Psychological Institute in North Smithfield. "It's clear that people who have this disorder suffer greatly and may be reluctant to seek help."

As word about the disorder spreads, the potential to identify and treat patients with the symptoms increases, said Guevremont.

Phillips is applying for a grant from the National Institute of Mental Health (NIMH) to study the effectiveness of treating adolescents' BDD with the antidepressant Prozac. Another NIMH grant already funds the same study on an adult population, a project that began in April 1995.

Doctors are also now showing increasing interest in BDD, as evidenced by the growing number of published reports on the disorder in psychiatric literature over the past few years, said Phillips.

Numerous people claiming to have BDD have contacted Phillips since her book was first published in 1996 and word of her research spread. Letters pile up on her office desk and the telephone rings with callers from as far away as England and India, relaying experiences and asking for help.

Phillips hopes that her research will ultimately "give a message of hope" to people like Jennifer, who had seen at least 15 dermatologists - most of whom had refused her treatment - before turning to Phillips.

"There are a lot of people out there suffering with this," said Phillips. "I'm sitting on mountains of data, and I want to write it up and get it out."

Bron : http://cgi-user.brown.edu/Administration/News_Bureau/1997-98/97-021.html

When the mirror holds you captive
They think they're ugly: Treating a debilitating body-image disorder

Dr. Katharine A. Phillips offers hope for sufferers of body dysmorphic disorder, a little-known disease in which people obsess about imagined flaws in their appearance. Antidepressants and cognitive-behavioral therapy may provide relief. (See also release number 97-049.)


PROVIDENCE, R.I. -- When Jennifer sought psychiatric help, she was 22 years old with long strawberry-blond hair, large green eyes and a beautiful complexion. She believed she was magnificently ugly:

I do go out sometimes, but mostly at night when no one can see me. Sometimes I go to a 24-hour grocery store at midnight, when I know no one else will be there. For a long time I've bought most of my clothes through catalogs. I'm too scared to go out - everyone will see how ugly I am.

Jennifer had body dysmorphic disorder (BDD), a debilitating disorder in which sufferers are obsessed with imagined flaws in their appearance. In The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (Oxford University Press), Katharine A. Phillips, M.D., writes about Jennifer and others afflicted with BDD.

Phillips, a Brown University psychiatrist based at Butler Hospital in Providence, R.I., estimates that as many as one in 50 people may have the disorder, most of them men and women in their 30s. People who suffer from BDD are typically obsessed with their face, skin or hair, but can be haunted by any part of the body.

Knowledge about the disorder in the medical community and the general public may help doctors, sufferers and their families identify the symptoms and seek help, Phillips says. Sufferers sometimes do not turn to psychiatrists because they attribute their obsession to their actual appearance, not their perception. Before visiting Phillips, Jennifer had seen 15 dermatologists, most of whom had refused her treatment.

The severity of BDD varies. Some sufferers obsess about perceived flaws from the moment they wake up. They check mirrors frequently, perform lengthy and elaborate grooming rituals before leaving the house, and frequently seek plastic surgery. Others are prisoners in their own homes, refusing to work, socialize, or even be seen in public. Cases documented in The Broken Mirror include people who missed family weddings, birthday parties and funerals because of their fears. Most sufferers think about their appearance more than three hours a day. In extreme cases, they have committed suicide.

Phillips devotes much of her time now to learning more about the disorder and finding a treatment. She is leading a study on the effectiveness of the antidepressant Prozac in treating adults with BDD. She has treated her own patients with some success, using various antidepressants and cognitive-behavioral therapy.

"Based on clinical experience, cognitive-behavioral therapy and serotonin-reuptake inhibitors [antidepressants such as Prozac] appear very, very promising," Phillips said, "but we need more studies. We are still very early in research on BDD."

Phillips is internationally known for her pioneering work on BDD, which only entered psychiatry's classification manual of disorders in 1987. Yet vivid case descriptions written during the last century testify to its history and presence in a variety of cultures.

There are people like Jennifer, who abandoned her car one afternoon in the middle of a traffic jam because she thought other drivers were staring at her. "All I could think was that they were looking at my face, thinking, `That poor girl; look at how ugly she is. How can she go out in public when her skin looks so bad?' "

Katharine A. Phillips, M.D., is chief of outpatient services and director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence, R.I., and assistant professor of psychiatry at the Brown University School of Medicine. She can be reached at (401) 455-6466.

Men as likely as women to suffer from body image disorder, study says

A study by psychiatrists at Butler Hospital in Providence, R.I., found a nearly equal sex ratio among patients with body dysmorphic disorder (BDD), as well as similarities in age of onset, course of illness and severity of symptoms between genders. (See also release number 97-021.)


PROVIDENCE, R.I. -- Although women are generally more dissatisfied with their appearance than men in this country, a study of nearly 200 people found that men are as likely as women to seek clinical help for the image obsession known as body dysmorphic disorder (BDD).

The study shows that BDD, a debilitating disorder in which sufferers are preoccupied with imagined flaws in their appearance, afflicts the sexes to a similar degree, though men and women obsess about different parts of the body, said Dr. Katharine A. Phillips, a Brown University psychiatrist and one of the study's two authors.

"Some people assume that because BDD involves the body image it is only seen in women," said Phillips. "Don't assume."

The study, reported in the September issue of The Journal of Nervous and Mental Disease, is the largest ever published on BDD, said Phillips, director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence.

In general, it is estimated that as many as one in 50 people have BDD. This study provided an overall picture as to the way the disorder afflicts men and women and found there are more similarities than differences.

The 93 women and 95 men in the study were patients in Phillips' practice. Predominantly unmarried and often unemployed, most of the patients started having symptoms of BDD during adolescence.

Differences between the genders centered mainly on the body part that was of concern to the patient. While men were often concerned with body build, hair loss and the size of genitals, women focused on weight and hips and the condition of their skin. These differences led to variations in the way the patients handled their perceived flaws. Men were likely to use a hat to camouflage the perceived defect whereas women were likely to use makeup.

Unexpectedly, the study found a similar rate of suicide attempts among patients with BDD despite the fact that women are twice as likely as men to attempt suicide in the general population. Also, although more women than men suffer from major depression, panic disorders and anorexia nervosa, the frequency was the same between male and female BDD patients.

Phillips conducted the study with Susan F. Diaz, M.D., of Butler Hospital.

The results are likely to be representative of what a psychiatrist would see in any clinical practice, said Phillips. However, large-scale studies still need to be done to determine the rate of occurrence in the general population. Also, future research will need to investigate whether gender ratio and gender differences are consistent across cultures. As psychiatrists learn more about this little-known disease, they will be better able to recognize sufferers, Phillips said.

Bron : http://www.biopsychiatry.com/bdd.htm

Selective processing of emotional information in body dysmorphic disorder by Buhlman U, McNally RJ, Wilhelm S, Florin I. University of Marburg, Germany.buhlmann@psych.mgh.harvard.edu J Anxiety Disord 2002;16(3):289-98

Body dysmorphic disorder (BDD) is a syndrome characterized by distress about imagined defects in one's appearance. Though categorized as a somatoform disorder, BDD is marked by many characteristics associated with social phobia (e.g., fear of negative evaluation) and obsessive-compulsive disorder (e.g., intrusive thoughts about one's ugliness, checking). In the present experiment, we tested whether BDD patients exhibit selective processing of threat in the emotional Stroop paradigm as do anxiety-disordered patients. Relative to healthy control participants, BDD patients exhibited greater Stroop interference for positive and negative words, regardless of disorder-relevance, than for neutral words. Further analyses suggested that interference tended to be greatest for positive words related to BDD. These data suggest that BDD patients are vulnerable to distraction by emotional cues in general, and by words related to their current concerns in particular. Results suggest that BDD may indeed be related to anxiety disorders such as social phobia.
Body dysmorphic disorder (BDD), a distressing and impairing preoccupation with an imagined or slight defect in appearance, is an "OCD-spectrum disorder" that appears to be relatively common. BDD often goes unrecognized and undiagnosed, however, due to patients' reluctance to divulge their symptoms because of secrecy and shame. Any body part can be the focus of concern (most often, the skin, hair, and nose), and most patients engage in compulsive behaviors, such as mirror checking, camouflaging, excessive grooming, and skin picking. Approximately half are delusional, and a majority experience ideas or delusions of reference. Nearly all patients suffer some impairment in functioning as a result of their symptoms, some to a debilitating degree. Psychiatric hospitalization, suicidal ideation, and suicide attempts are relatively common. While treatment data are preliminary at this time, selective serotonin reuptake inhibitors (SSRIs) appear to often be effective for BDD, even if symptoms are delusional. Cognitive-behavioral therapy is another promising approach. While much remains to be learned about BDD, it is important that clinicians screen patients for this disorder and accurately diagnose it, as available treatments are very promising for those who suffer from this distressing and sometimes disabling disorder.

Bron : http://hallhealth.com/mental_health/225.shtml

Booknews, Inc.
The first volume to appear on the newly labeled dysmorphic disorder (BDD) pattern which is characterized by a person's debilitating obsession with perceived flaws in their appearance. If one thinks that BDD might simply be a new age coinage for vanity, Phillips (psychiatry, Brown U. School of Medicine) makes a convincing case for taking a second look by drawing on years of clinical practice, research, and patient interviews. The evidence demonstrates that the obsession often causes sufferers to attempt suicide or become house bound and can be linked to eating disorders and depression. Suggesting new treatment methods (therapy, Prozac) and methods of assessing BDD, Phillips legitimizes a serious malady that many sufferers keep secret. --This text refers to the hardcover edition of this title
Dr. Phillips draws on years of clinical practice and detailed interviews with more than 200 patients to bring readers the first book on body dysmorphic disorder, or BDD, in which sufferers are obsessed by perceived flaws in their appearance.

Philips draws on years of clincial practice and detailed interviews with over 200 patients to bring readers the first book on Body Dysmorphic Disorder (BDD), a debilitating disease in which sufferers are obsessed by perceived flaws in their appearance. --This text refers to the hardcover edition of this title

In The Broken Mirror, Dr. Katharine Phillips draws on years of clinical practice, scientific research, and detailed interviews with patients to bring readers the first book on this troubling, and sometimes debilitating, disorder, in which sufferers are obsessed with perceived flaws in their appearance. Phillips describes severe cases, but also milder cases, such as Carl, a successful lawyer who uses work to distract him from his slightly thinning hair. Many sufferers function well, but remain secretly obsessed by their "hideous acne" or "horrible nose," sneaking constant peeks at a pocket mirror, or spending hours redoing makeup. BDD afflicts millions of people. It isn't an uncommon disorder, simply a hidden one, since sufferers are often embarrassed to tell even their closest friends about their concerns: one woman, after fifty years of marriage, still kept her appearance worries a secret from her husband. Besides the fascinating story of the disorder itself, The Broken Mirror is also a lifesaving handbook for sufferers, their families, and their doctors. Left untreated, the torment of BDD can lead to hospitalization and sometimes suicide. With treatment, many sufferers are able to lead normal lives. Phillips provides a quick self-assessment questionnaire, helping readers distinguish between normal appearance concerns and the obsession of BDD to determine whether they or someone they know have BDD. She includes common clues to BDD - such as frequent mirror checking, covering up with clothing, and excessive exercise. Other chapters outline treatments using medication and cognitive-behavioral therapy. Finally, Phillips includes a chapter for the friends and families of BDD sufferers. Profoundly affected by the disorder themselves, those who care about someone with BDD will find both helpful advice and reassurance in this indispensable book.

Bron : http://www.athealth.com/Consumer/disorders/bddinterview.html

Body Image and Body Dysmorphic Disorder

Athealth.com is pleased to welcome J. Kevin Thompson, PhD, co-author of Exacting Beauty: Theory, Assessment, and Treatment of Body Image Disturbance, who answers questions about body image and body dysmorphic disorder (BDD).

Athealth.com: Tell us about your professional background.

Dr. Thompson: I am a professor of psychology in the Department of Psychology at the University of South Florida, where I have been since 1985. I received my PhD in clinical psychology from the University of Georgia in 1982.

Athealth.com: How did you become interested in problems related to body image?

Dr. Thompson: My early work was in the treatment of obesity and in the development of strategies to increase participation in physical fitness programs. These interests evolved into a focus on eating disorders in the early 80s at a time when bulimia nervosa was just becoming recognized as a clinical disorder. My early work in eating disorders focused on body image, with findings that body dissatisfaction was not limited to individuals with anorexia nervosa and/or bulimia nervosa, but was, in fact, present in individuals without eating disorders. Since the mid-80s, my work has consisted of a variety of studies focused on body image in diverse samples, such as in athletes, plastic surgery patients, adolescents, adults, and individuals of different ethnicity and countries.

Athealth.com: How do you define body image? How does this relate to body image disturbances?

Dr. Thompson: Body image is an internal view of one's own appearance. It is, in effect, how we see ourselves. However, it is multifaceted and consists of several components. For instance, there is the issue of accuracy of body perception - Do you see what others see? Overestimating the size of certain body sites (such as waist and hip size) when compared to objective measurements has often been noted as a sign of body image disturbance. However, more often the perception is not truly distorted, but rather, some aspect of appearance is disliked, disparaged, or seen as unacceptable.

Indications of this subjective distress can be assessed with a wide variety of questionnaires or figural rating scales. These measures may indicate high levels of body dissatisfaction, negative thoughts, or cognitions associated with certain body parts, or even high levels of social avoidance due to negative feelings about the body. In our book, Exacting Beauty, my co-authors and I have reproduced over 30 of the most commonly used body image scales.

Body image may be seen as "disturbed" when one's self-evaluation of appearance is at such a level that it interferes with social and/or occupational functioning, or causes elevated levels of anxiety and depression in the individual.

Athealth.com: What are the features or characteristics of body dysmorphic disorder? How does BDD manifest itself?

Dr. Thompson: The primary feature is a person's extreme disparagement of some aspect of his/her appearance. Importantly, the individual's rating of the body feature does not fit with that of an objective observer, who may not see anything unattractive or unusual about the feature, or who may note some minimal problem (i.e., the nose or ears may be a bit larger than "average"). What is perhaps most important from a clinical viewpoint is that the individual is obsessively focused on the disliked body feature, and this obsession severely interferes with that person's existence.

BDD may occur for a variety of appearance features. However, prevalence studies indicate that the following sites are reported frequently: hair, nose, skin, eyes, thighs, abdomen, breast size or shape, chest size, lips, chin, scars, height, and teeth.

Athealth.com: Isn't it true that most people show at least some signs of dissatisfaction with one or more aspects of their appearance?

Dr. Thompson: Almost everyone has some body feature that they would like to modify. In the case of BDD, the individual will go to great lengths to modify the body site (via surgery, exercise, diet, etc.) or cover the feature (via make-up, clothing).

Athealth.com: What causes BDD? Are there factors that predispose a person to BDD?

Dr. Thompson: There is little definitive research on the causes of BDD and the factors that predispose a person to BDD. Much of the work in this area comes from an examination of case studies and the factors that patients relate to the onset of symptoms. In many of these cases, it seems that some event precipitates an initial selective focus on a specific body site. Often the event consists of a negative or teasing comment from someone directed at the appearance feature ("Hey, Dumbo"). Sexual abuse or harassment may also be a precipitant. In perhaps 70% cases, the onset of symptoms begins in adolescence.

Athealth.com: How severe is BDD?

Dr. Thompson: BDD may lead a person to engage in extreme avoidance behaviors, such as isolation from acquaintances and even loved ones. Suicidal behavior is not uncommon, and clinical depression may also eventuate. In some cases, multiple surgeries and body modification efforts (such as compulsive weightlifting) fail to improve the person's view of the appearance "defect."

Athealth.com: How prevalent is BDD? What populations are affected?

Dr. Thompson: : Prevalence studies have not been conducted. However, it is likely that the disorder is rare, perhaps affecting between 1.0-2.0% of the general population and 10-15% of psychiatric outpatients. Some researchers believe that the prevalence is on the rise, as diagnostic methods become better at detecting the problem and as society becomes even more obsessed with appearance. Interestingly, studies suggest that BDD may be equally common in adult females and males. This is in sharp contrast with the data for eating disorders, which suggests that about 90% of the cases are females. However, in the only study to date of prevalence in adolescents, only 9% of the cases were boys. To date, we have little other information regarding prevalence in specific populations and whether or not there is a connection within families.

Athealth.com: How is body dysmorphic disorder distinguished from eating disorders and from obsessive-compulsive disorder (OCD)?

Dr. Thompson: Certainly, someone with an eating disorder may also show signs of body dysmorphia, especially if there are signs of body image disparagement for a weight-related body site (waist, hips, thighs). The presence of BDD with a site that is non-weight-related (nose, ears) usually indicates that there is no co-occurring eating disorder. However, if the BDD site of concern is a weight-related site, then an assessment for an eating disorder should be undertaken with a focus on the usual eating disordered symptoms of excessive dieting, weight loss, purging, and feelings of loss of control surrounding food.

It is very difficult to distinguish BDD from OCD, and some researchers and clinicians believe that BDD is an OCD "spectrum" disorder (i.e., it has the same core symptoms, but with the focus of the OCD cognitions and behaviors on an aspect of appearance). In fact, the psychological and pharmacological therapies are similar for both disorders.

Athealth.com: Are other psychiatric conditions associated with BDD?

Dr. Thompson: Disorders commonly found to be associated with BDD include depression and social anxiety problems (social phobia, avoidant personality disorder). However, once again, there is little real empirical work in this area.

Athealth.com: How is BDD diagnosed?

Dr. Thompson: There are two primary methods. First, because BDD is a specific DSM disorder, there are clearcut diagnostic criteria available. On p. 445 of the American Psychiatric Association's, Diagnostic and Statistical Manual for Mental Disorders (APA, 1994), criteria are provided. These criteria focus on the excessive preoccupation with an "imagined defect in appearance" or one where a "slight physical anomaly is present."

In addition, James Rosen of the University of Vermont has developed an interview scale specific to BDD, which he calls the Body Dysmorphic Disorder Examination. He has used this in several studies, and it is an excellent tool for cataloging BDD symptoms and facilitating an accurate diagnosis of the disorder. This interview scale contains 34 items that index the core symptoms and associated features of BDD, including the following:
How often the patient experiences upsetting preoccupation with appearance.
How often the patient thought other people were scrutinizing his/her defect.
How often the patient camouflages or hides his or her appearance defects with clothes, make-up, and so forth.

Athealth.com: How is BDD treated? How successful are the various forms of treatment?

Dr. Thompson: There are very few controlled outcome studies on the treatment of BDD. Encouraging results have been found with medication (serotonin reuptake inhibitors, i.e., clomipramine) and cognitive-behavioral treatment strategies (i.e., exposure and response prevention). The latter techniques focus on breaking compulsive patterns, such as checking in the mirror and asking others for reassurance. In addition, social avoidance is countered by helping patients learn to deal with social situations that promote appearance anxiety. Again, James Rosen of the University of Vermont has pioneered the use of these techniques for BDD. (See his chapter on BDD in my 1996 book, Body Image, Eating Disorders and Obesity.)

Athealth.com: Is it common for a person with BDD to go untreated?

Dr. Thompson: It is difficult to determine how many people are untreated. However, since many clinicians and family members may not yet recognize the warning signs of BDD, it is likely that a large number of those suffering have not received treatment.

Athealth.com: What should a person do if a friend or family member has BDD? How can friends and family help in the recovery process?

Dr. Thompson: The best option is to refer the individual to a mental health professional with expertise in BDD or, minimally, with expertise in eating disorders and/or OCD. The role of family or friends in the recovery process is a complicated one. The therapist may ask them to resist responding to reassurance-seeking behavior on the part of the patient regarding appearance concerns. Otherwise, it is best for the significant other to refrain from challenging the veracity of the patient's complaints ("But I don't see anything wrong with your hair.") because this invalidates the views of the patient. Conflict is liable to arise out of attempts at assistance. It is perhaps best that family and friends simply listen and offer support and defer any active modification attempts to the professional.

Dr. Thompson also authored of Body Image Disturbance: Assessment and Treatment (Pergamon Press, 1990) and edited Body Image, Eating Disorders, and Obesity : An Integrative Guide to Assessment and Treatment (American Psychological Association, 1996). He is on the editorial board of the International Journal of Eating Disorders

Bron : http://www.nami.org/youth/dysmorphic.html

Katharine A. Phillips, M.D., is chief of outpatient services and director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence, R.I., and assistant professor of psychiatry at the Brown University School of Medicine.
Youth with body dysmorphic disorder (BDD) worry about some aspect of their appearance. They worry, for example, that they have pimples or that their skin is scarred or bumpy, their nose is too big, they are fat or too thin. Or they may think something else is wrong with how they look. When others tell them that they look fine or that the flaw they perceive is minimal (or nonexistent), youth with this disorder find it hard to believe this reassurance.

Adolescents with BDD think a lot about their perceived physical flaw, generally for at least an hour a day. Some say they're obsessed. Most find that they don't have as much control over their thoughts about the body flaw as they would like.

In addition, the appearance concern causes significant distress (for example, anxiety or depression) or it causes significant problems in functioning. Although some youth with this disorder manage to function well despite their distress, many find that their appearance concerns cause problems for them. For example, they may find it hard to concentrate on their job or schoolwork, which may suffer, and relationship problems are common. Adolescents with BDD may have few friends, avoid dating, and feel very self-conscious in social situations.

Obsessive mirror-checking may seem normal for teens in their formative years, but is the image some see causing severe angst-even causing some to contemplate suicide? "These adolescents have a very distorted view of how they look, and it does not match how other youth see them," says Dr. Katharine Phillips, who recently co-authored one of the first studies of BDD in youth. Teens plagued with BDD are obsessed with negative perceptions of their bodies. Many times they end up dropping out of school, suffering major depressive episodes, avoiding most social contact, and even attempting suicide in some cases. BDD can be a devastating disorder for adolescents, and it is thought to be caused by a chemical imbalance in the brain.

The severity of BDD varies. Some youth experience manageable distress and are able to function well, although not up to their potential. Others find that this disorder ruins their life. BDD also has some features that, while not necessary for the diagnosis, can provide clues to its presence, some of which are the following:

Some clues to the presence of BDD-


frequently comparing one's appearance with that of others, or scrutinizing the appearance of others;
often checking how one looks in the mirror;
camouflaging the perceived defect with clothing, makeup, a hat or a hand, or changing one's posture;
seeking surgery, dermatologic treatment, or other medical treatment for appearance concerns when doctors, parents, or peers have said such treatment is unnecessary;
constantly seeking reassurance about the perceived flaw or attempting to convince others of its repulsiveness;
excessive grooming (combing one's hair, shaving over and over, removing or cutting hair, applying makeup or cover-up creams);
picking at one's skin or squeezing pimples/blackheads for hours;
avoiding mirrors;
exercising or dieting excessively;
frequently touching the perceived defect;
measuring the "unpleasant" body part;
excessively reading about the supposed defective body part;
avoiding social situations in which the perceived defect might be exposed; and
feeling very anxious and self-conscious around peers because of the perceived defect;
BDD is often underdiagnosed

The diagnosis of BDD is often missed because of:

trivialization: BDD is easily trivialized, even though it is a serious and distressing condition;
secrecy and shame: many adolescents with BDD don't reveal their symptoms to others because of embarrassment;
lack of familiarity with BDD: many health professionals, including primary healthcare providers, are not aware that BDD is a known psychiatric disorder that often responds to psychiatric treatment; or;
pursuit of non-psychiatric, medical, and surgical treatment: many youth with BDD see dermatologists, plastic surgeons, and other physicians rather than mental health professionals. These treatments often are not helpful.
BDD can be misdiagnosed

BDD is often misdiagnosed as a different psychiatric disorder. This occurs because BDD can produce symptoms that mimic other disorders such as social phobia, agoraphobia, panic disorder, trichotillomania (excessive hair pulling), obsessive-compulsive disorder, and depression.

Hope for BDD sufferers

Psychiatric treatment is often effective in decreasing BDD symptoms and the suffering they cause. The treatments that appear most effective are certain medications, namely the selective serotonin reuptake inhibitors (SSRIs), and cognitive behavioral therapy.

The prescription-only SSRIs are not addicting and are usually well tolerated. They can significantly relieve BDD symptoms by diminishing bodily preoccupation, distress, depression, and anxiety and by significantly allowing increased control over the youth's thoughts and improving functioning. In some cases these medications are lifesaving, especially for those who have attempted suicide in their despair over their appearance.

During cognitive-behavioral therapy the specially trained therapist helps the person with BDD resist compulsive behaviors-for example, mirror checking-and face avoided situations like social situations. It's important to determine whether a therapist has been specifically trained in cognitive-behavioral therapy. Other types of talk therapy do not appear to be effective for BDD.

BDD treatment trial in adolescents

Drs. Katharine Phillips and Ralph Albertini are conducting the very first treatment trial in adolescents with BDD, funded by the National Institute of Mental Health. The trial, which will study 100 adolescents over the next four years, will take place at three sites: Providence, Rhode Island; Cincinnati, Ohio; and New York City.

For more information about BDD

The most comprehensive source on body dysmorphic disorder is The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder by Katharine A. Phillips, M.D. (Oxford University Press). It can be ordered through bookstores or by calling (toll free) 1-800-451-7556. For more information on the treatment trial, call (401) 455-6466.

Body Dysmorphic Dysfunction

Bron : http://www.emedicine.com/ped/topic2122.htm

Background: The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), defines body dysmorphic disorder (BDD) as a preoccupation with an imagined defect in appearance (eg, a large nose). The patient may have an exaggerated sense of the severity of the perceived physical flaw. This excessive preoccupation results in notable emotional distress and impairment in function in school, work, home, or other important life functions.

Patients with BDD seek ways, such as cosmetic surgery, to "correct" their perceived malformation. Patients with symptoms focused on the preoccupation with body weight and shape or perceived inappropriateness of sexual characteristics are not defined as BDD and frequently meet criteria for disorders such as anorexia nervosa or gender identity disorder.

Pathophysiology: The pathophysiology of BDD still is unknown at this time though a number of theories have been suggested. Sociologically speaking, BDD has been explained as an excessive interpretation of society's ideals of physical beauty, and an overvaluing of available cosmetic procedures to correct such "flaws." Patients with BDD often are insecure, sensitive, obsessional, schizoid, anxious, narcissistic, introverted, and have hypochondriac traits. Because BDD has a strong association with hypochondriasis and other conditions that involve obsessional thoughts, using a neurobiologic approach, BDD is believed to respond preferentially to selective serotonin reuptake inhibitors (SSRIs). There is some evidence that BDD and other obsessive-compulsive disorders (OCDs) may be aggravated by m-chlorophenylpiperazine, a partial serotonin agonist.


In the US: An estimated 1% of the population is affected by BDD.
Internationally: In cosmetic surgery and dermatology settings, it is estimated that from 6%-15% of patients have body dysmorphic disorder.
Mortality/Morbidity: Phillips et al studied functional impairment in 130 patients with BDD

Social dysfunction: Thirty-two percent of patients have been housebound at least for a week based on their symptoms. Ninety-eight percent of individuals in the group have significant impairment in social functioning. Seventy-four percent of patients have impairments in academic or occupational functioning. Thirteen percent of affected individuals have received government disability payments due to BDD.
Suicide risk: A distinct risk of suicide exists, especially in women. Twenty-nine percent of the BDD group studied made at least one suicide attempt. Sixty percent of these attempts were due to BDD symptoms.

Race: No racial predilection exists.

Sex: The gender distribution of body dysmorphic disorder is not known. When it occurs in males, preoccupations are often related to obsessions about their genitalia. Women with body dysmorphic disorder often are preoccupied with their hair, face, and breasts.

Age: BDD generally starts during adolescence and is usually continuous over time, with waxing and waning symptoms. For many patients, it becomes chronic. The body part that is the focus of concern may remain the same or change over time.


Natural history
BDD is a chronic disorder that can wax and wane in intensity.
The symptoms often start during adolescence. Over the course of a lifetime, new symptoms may be added onto the original presentation, or symptoms may shift from one body part to another.
Body dysmorphic disorder may not be diagnosed for many years after its onset often due to the patient's reluctance to reveal the symptoms. In some cases patients who are ashamed of their symptoms may not identify individual symptoms, referring only to a sense of "general ugliness."
Body dysmorphic disorder may lead to time consuming unproductive rumination. Patients adopt repetitive, obsessive, and ritualistic behavior and may spend the majority of their time in front of a mirror, repeatedly checking their perceived imperfections.
Body dysmorphic disorder is associated with significant social impairment ranging from diminished social activities to extreme social isolation. In severe cases, individuals may leave home only at night, and avoid job interviews, dating, and peers.
Patients also have a constant need for reassurance about their perceived flaws and often can be extremely demanding to primary care physicians and cosmetic surgeons in their pursuit for perfection.
Common areas of perceived imperfections
Excessive greasiness
Excessive facial hair
Nasal size and shape
Bite of jaw
Physical: Patients with BDD often have no distinguishing physical/dermatological findings.

Causes: Causes are unknown at this time.

Medical Care: Treatment of BDD may include cognitive-behavioral psychotherapy, pharmacologic interventions, and other psychosocial interventions that promote social functioning.

Treatment goals
Prevent adoption of the sick role

Minimize unnecessary costs and complications by avoiding unwarranted hospitalizations, diagnostic and treatment procedures, and medications, especially avoiding corrective surgeries.

Pharmacological control of comorbid syndromes and BDD
Psychotherapy and psychosocial strategies and techniques
Consistent treatment, generally by the same physician

Supportive office visits scheduled at regular intervals

Focus gradually shifted from symptoms to personal and social problems

Cognitive behavioral therapy involving prevention of body inspection rituals and reassurance seeking
Pharmacologic and physical strategies and techniques
Avoid drugs with abuse or addictive potential.

SSRIs may be helpful in controlling obsessional thinking. Clomipramine is another option.

In recent years, SSRIs have appeared to be useful in the treatment of BDD. Other classes of drugs including TCAs, benzodiazepines, neuroleptics, and anticonvulsants have produced minimal or no improvement. In general it is recommended that medications be used in conjunction with psychosocial interventions such as cognitive-behavioral therapy.
Drug Category: Selective serotonin reuptake inhibitors (SSRIs) -- Used for the treatment of BDD. Antidepressant agents chemically unrelated to the tricyclic, tetracyclic, or other available antidepressants. Inhibit CNS neuronal uptake of serotonin (5HT). May have a weak effect on norepinephrine and dopamine neuronal reuptake. Have been used to treat patients with anxiety, phobias, or obsessive-compulsive disorders.

Drug Name
Fluvoxamine (Luvox) -- Potent selective inhibitor of neuronal serotonin reuptake. Does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and, thus, has fewer adverse effects than tricyclic antidepressants.
Adult Dose 50 mg PO hs initially, then increase by increments of 50 mg/d q4-7d to 250 mg PO qd; administer for at least 2-3 mo
Pediatric Dose <8 years: Not recommended
>8 years: Administer as in adults
Contraindications Documented hypersensitivity; do not administer within 14 d of MAOIs; cisapride (ie, increases risk of prolonged QT interval)
Interactions Risk of a hypertensive crisis increases in coadministration with MAOIs
Inhibits CYP450 isoenzymes 1A2, 2C9 (potent inhibitor), 2C19, 2D6, 3A4 (potent inhibitor); fluvoxamine potentiates effect of isoenzyme substrates mentioned (eg, triazolam, alprazolam) and thus, when taking them concurrently, dose should be reduced by at least 50%; reduce also the dose of theophylline by one third; monitor plasma levels if taking it concurrently with fluvoxamine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity
Serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk before SSRIs
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in liver dysfunction, cardiovascular disease, history of seizures, or suicidal tendencies

Drug Name
Fluoxetine (Prozac) -- Selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.
Adult Dose 10-20 mg/d PO initially; increase over several weeks to 40 mg PO qd; administer for at least 2-3 mo
Pediatric Dose Not established; although used to treat depression in children
Contraindications Documented hypersensitivity; do not administer within 14 d of MAOIs
Interactions Potent inhibitor of CYP450 3A4; increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs, and highly protein-bound drugs; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk before SSRIs
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in hepatic impairment and history of seizures
Drug Category: Tricyclic antidepressant agents -- Use when SSRIs are ineffective. Structurally related to the phenothiazine antipsychotic agents. Exhibit 3 major pharmacologic actions in varying degrees, (ie, amine pump inhibition, sedation, anticholinergic action [peripheral and central]). Inhibit reuptake of norepinephrine or serotonin (ie, 5-hydroxytryptamine, 5-HT) at the presynaptic neuron.Drug Name
Clomipramine (Anafranil) -- Affects serotonin uptake while it affects norepinephrine uptake when converted into its metabolite desmethylclomipramine.
Adult Dose 25 mg PO hs initially; gradually increase to 175 mg PO qd; administer for at least 2-3 mo
Pediatric Dose Not established; although used to treat OCD in children
Contraindications Documented hypersensitivity; recent myocardial infarction; do not use within 14 d of MAOIs
Interactions Barbiturates, phenytoin, and carbamazepine, decrease effects; clomipramine increases effects of anticholinergics, sympathomimetics, alcohol and CNS depressants; toxicity of MAOIs increases with clomipramine
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in severe cardiopulmonary or renal impairment and those unable to metabolize sorbitol

Further Outpatient Care:

Patients have best results when treated by a consistent medical and mental health team.
Cognitive behavioral therapy may be beneficial in situations during which patients develop a structured and predictable strategy in order to identify cognitive errors and maladaptive thinking.
When cognitive-behavioral therapy is efficacious, patients learn to alter cognitive distortions and are able to maintain and generalize more adaptive thought patterns in daily life.

In/Out Patient Meds:

Patients may benefit most from a combination of SSRIs in conjunction with therapy sessions. Maximum benefit of SSRI medication may take several months.

Practitioners must be made aware that patients with BDD are at a higher risk for suicide.

BDD is a chronic disease, and the goal of therapy is to keep symptoms controlled.

Medical/Legal Pitfalls:

BDD is sometimes overlooked as a diagnosis since many patients are reticent about discussing their symptoms. Failure to make this diagnosis can be dangerous since these patients are at increased risk for suicide. Patients with BDD are also at risk for repeated cosmetic surgery to "correct" their perceived but nonexistent problem.

Allen A, Hollander E: Body dysmorphic disorder. Psychiatr Clin North Am 2000 Sep; 23(3): 617-28[Medline].
Cotterill JA: Body dysmorphic disorder. Dermatol Clin 1996 Jul; 14(3): 457-63[Medline].
Neziroglu F, Hsia C, Yaryura-Tobias JA: Behavioral, cognitive, and family therapy for obsessive-compulsive and related disorders. Psychiatr Clin North Am 2000 Sep; 23(3): 657-70[Medline].
Siberry GK, Iannone R, eds: The Harriet Lane Handbook. 15th ed. Mosby-Year Book; 2000: 615-891.
Tasman A, Jerald K, Lieberman J, eds: Body dysmorphic disorder. In: Psychiatry. Philadelphia, Pa: WB Saunders Co; 1997: 1148-1151.

Body Dysmorphic Disorder

Bron : http://www.psychnet-uk.com/dsm_iv/body_dysmorphic_disorder.htm

This disorder, formerly referred to as dysmorphophobia, tends to occur in young adults equally in either gender. The patient becomes pre-occupied with a non-existent or minimal cosmetic defect (nose, cleft chin, blemish, breast size) and persistently seeks medical attention to fix it surgically. It is suggested that this tends to be a mild disorder which may occur in pre-disposed neurotic individuals. Some feel it is a variant of obsessive-compulsive disorder. Many do well with surgery, but some remain persistently disgruntled. It is important to distinguish them from psychotic patients and those with highly disturbed global and body self-images, since those patients will not be improved by surgery. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

Body dysmorphic disorder therefore is characterized by certain key and associated features, specifically preoccupying obsessions with a particular body part that the person considers unattractive.

Cases of body dysmorphic disorder can range from relatively mild to very severe. People with mild cases are bothered and distressed, and their obsessions cause some degree of impairment. The patient is preoccupied with an imagined defect of appearance or is excessively concerned about a slight physical anomaly.

This preoccupation causes clinically important distress or impairs work, social or personal functioning.

Another mental disorder (such as Anorexia Nervosa) does not better explain the preoccupation.

Associated Features

Depressed Mood
Somatic or Sexual Dysfunction
Guilt or Obsession
Anxious or Fearful or Dependent Personality

Body Dysmorphic Disorder

Bron : http://www.beautyworlds.com/bodydd.htm

by Michael Sones

Dissatisfaction with appearance is very prevalent in our society. Over the past three decades the popular magazine Psychology Today has conducted several surveys on how people feel about the appearance of their bodies. The changing results make for interesting reading. The dramatic changes in American culture have significantly altered peoples' perceptions of themselves. In 1972 twenty-three percent of American women were dissatisfied with their appearance but by 1997 that figure had risen to fifty-six percent. In 1972 fifteen percent of men were dissatisfied with their appearance but by 1997 that figure had risen to forty-three percent. Thirty-eight percent of men are now dissatisfied with the size of their chests compared to the thirty-four percent of women dissatisfied with their breasts. Men are getting pectoral and calf implants. Millions of women have had surgery to change the shape of their breasts or increase their size.

Dissatisfaction with how you look is practically the norm. However, when someone becomes intensely preoccupied with what they believe to be a defect in their appearance, then they may be suffering from a mental health condition called Body Dysmorphic Disorder (BDD). While there may be a real basis for the concern, as for example, where acne is present, the sufferer's preoccupation is intense and excessive. Other times the perceived imperfections may not be obvious to anyone other than the person. They feel intensely tormented and tortured by what they feel makes them ugly to themselves and to those around them. It used to be called dysmorphobia and was first described by an Italian psychiatrist, Enrique Morselli, over a hundred years ago. He was aware of the intense suffering caused by the preoccupation with the imagined defect.

This condition often goes undiagnosed and the sufferer may seek repeated cosmetic surgery to remedy the imagined defects. People with this disorder commonly complain about flaws of the head or face. They may be preoccupied with the size and shape of noses, eyes, ears and mouths, eyebrows, chins, and jaws. People may also agonize over the real or imagined appearance of wrinkles, the shade of their skin, the degree of facial symmetry, or thinning hair. This intensive and time-consuming preoccupation may also focus on other body parts, such as arms, legs, tummy, hips, and genitals. Where the person's obsessive interest is in their weight, body shape and size, a differential diagnosis of Anorexia Nervosa may be made.

People with BDD may find themselves constantly checking their appearance in the mirror. The checking is constant because they never feel reassured. In some cases the level of dissatisfaction in their appearance may lead sufferers to shun the company of other people, in work and social situations. This is partly because being with other people may lead people with BDD to compare their perceived defective parts with others and leads to an increase of anxiety. It can also be because BDD sufferers often feel that others are staring at them, noting their defects and then mocking or criticizing them behind their backs.

BDD usually begins in adolescence, probably because this is a time when young people are having to cope with natural changes in their body shapes and sizes. Issues of sexuality and gender identity also arise at this time, as do impulses to move from the family nest out into the community where future potential mates reside. Many, if not all, teenagers experience anxiety about the many changes that occur within and without their bodies at this time; for most the anxiety is temporary and manageable while for others it is the beginning of a very long course of unhappiness with themselves. This condition occurs at about the same rate in males and females. The current tendency to idealize thinness, as illustrated by images of slender models in the media, has a particular impact upon girls because the development of breasts and hips seems to be in conflict with the cultural ideal. Due in the main to modern nutrition the average woman has become even larger and thus conflicts even more with the cultural ideal of thinness. Puberty seems to be occurring at even younger ages and it may be that younger children will become affected by body image disturbances. The natural change which boys undergo as they become taller and more muscular is more in tune with the cultural ideal for men.

BDD can be very serious and disabling. The disorder is often associated with depressive disorders and social phobia. If someone comes and presents with a depressive disorder it is recommended that the possibility of an associated body dysmorphic disorder be explored. This is because BDD sufferers often find it extremely embarrassing to disclose their worries. The great distress it causes can lead sufferers to serious suicide attempts.

It is difficult to know just how prevalent BDD is as there is such a great cultural preoccupation with beauty and attractiveness and giving lots of attention to the body. This may mask and normalize what might be seen in other cultures to be an excessive interest in one's appearance. For example, what would be a "normal" amount of time to spend doing one's makeup, or a "normal" amount of cosmetic surgery to have?

Treatment with medication, particularly fluoxetine, is effective in many cases but there are also a number of cases which do not respond to treatment. Cognitive behavioral therapy has also been effective.

The author of this article is a qualified and experienced psychotherapist with many year experience working for the NHS in the UK. Information in this article is purely for educational purposes. If you suspect you may be suffering from BDD please seek appropriate help from your doctor or a properly qualified mental health clinician.



Differential Diagnosis

Some disorders display similar or sometimes even the same symptom. The clinician, therefore, in his diagnostic attempt has to differentiate against the following disorders which one needs to be ruled out to establish a precise diagnosis.

General medical conditions;
Major Depressive Disorder;
Social Phobia;
Obsessive-Compulsive Disorder;
Anorexia Nervosa;
Bulimia Nervosa.


Although we still do not have a single clear cause for body dysmorphic disorder, authorities believe that biological, psychological and perhaps even social or cultural factors contribute to its origins.



Counseling and Psychotherapy [ See Therapy Section ]:

Cognitive-behavior therapy which includes education about BDD and its treatment, and specific treatments to deal with faulty thoughts, assumptions ("cognition's") and problematic behaviors. The cognitive aspects involve discovering, challenging and changing the underlying negative thoughts and beliefs the sufferer keeps thinking.

The treatment's behavioral components usually focus on exposure and response prevention. Exposure usually involves having the sufferer gradually learn to face and confront the situations they fear the most, such as going into public places or exposing their embarrassing body part to others' scrutiny without hiding or camouflaging it. Response prevention involves getting the sufferer to conscientiously and diligently refuse or avoid doing the self-damaging behaviors they feel compelled to do, such as staring endlessly into mirrors or picking at one's face. When sufferers are able to delay such behaviors long enough, the impulse to do them sometimes dies down, and these behaviors may be thwarted.

Available evidence suggests that medication and cognitive-behavior therapies can complement each other well. In addition to these treatments, family education and counseling, to help family members understand what is going on and how to help the sufferer, and group therapy or support for those with BDD may be of benefit.


Pharmacotherapy [ See Psychopharmacology Section ] :

Treatment with SRIs. These same SRI medications are also used to treat depression, obsessive-compulsive disorder (OCD) and other anxiety conditions.

Fluoxetine Prozac;
Fluvoxamine Luvox;
Paroxetine Paxil;
Sertraline Zoloft;
Citalopram Celexa;
Clomipramine Anafranil

When Appearance Becomes an Obsession
Ralph S. Albertini, M.D. and Katharine A. Phillips, M.D. - Author of The Broken Mirror
Brown University Medical College

Bron : http://www.worldcollegehealth.org/031199.htm

Sarah's Story

Sarah knew something was wrong - very wrong but she couldn't bring herself to tell anyone about her secret. Not her best friend, her college roommate, or even her boyfriend knew. It was just too embarrassing. Sarah knew that she overreacted to her skin problem; the acne just wasn't that bad, but she couldn't stop thinking about it. Was it as bad as yesterday? Did the new cream from the dermatologist help? Was it making things worse? Were people noticing it more? Nor could she stop checking her acne in the mirror and picking at her skin, which she knew only made it worse. And she couldn't stop asking others over and over about how she looked. No matter how reassuring their answers were, she got only a little temporary relief from her anxiety. Sarah believed that she had terrible acne, which made her feel that she was truly ugly. In reality, other people hardly noticed her minimal blemishes. And now, because of her embarrassment, she was spending more and more time alone in her room. She was missing more and more classes and not participating in class discussions when she did go to class. She was also avoiding social opportunities. Her grades were slipping, and her boyfriend was growing impatient with her isolation and endless requests for reassurance.

Isn't Everyone Concerned About Their Appearance?

Lots of people worry about their appearance, especially in their teens and twenties, when physical attractiveness, changing bodies, and social pressures come together to make appearance seem more important than ever. Who wouldn't want perfectly clear lustrous skin, a beautiful head of richly colored hair, and the perfect physique? The answer for most people is sure, why not? But for some people, normal appearance concerns cross over into preoccupation or even obsession with their appearance. In more severe cases, these concerns seriously interfere with school work and relationships, and they cause significant distress. This relatively common but underrecognized disorder is known as body dysmorphic disorder, or BDD. Because BDD can cause so much suffering and disruption of normal functioning, it's important to know about it. BDD, which usually begins during adolescence, can cause depression, social isolation, academic impairment, and, in more severe cases, unnecessary cosmetic surgery, psychiatric hospitalization, and even suicide attempts.

Justin's Story

Justin was a college sophomore who had never gone outside his dorm room without his baseball cap on. He was certain that his hair was thinning and that he was rapidly going bald. Because of this, he had chosen a college that had a very loose dress code so he could wear his cap at all times, even to class. He also requested a single room so he wouldn't have to suffer the embarrassment of exposing his uncovered head to his roommate. Justin's problems began during his junior year in high school, when one day while passing a department store he glanced at his reflection in the window and noticed what appeared to be male-pattern hair loss. Shortly thereafter he began to wear his baseball cap and avoid any social situations where he might have to take it off. Before going to college he had visited seven different dermatologists for treatment of what he was sure was major hair loss. Each dermatologist tried to reassure him that what he was noticing was normal for his age and didn't indicate any significant hair loss or early baldness. Nevertheless he continued to look for answers, spending hours on the internet trying to find remedies. He asked his mother fifteen to twenty times a day if she thought his hair looked any thinner. At one point his mother took him for family counseling because she said that he was driving her crazy with his questions. Justin thought about his hair for hours a day. This caused him to fall behind in his classes and disrupted his ability to pay attention while in class. He was close to failing when he was referred to a psychiatric clinic where body dysmorphic disorder was diagnosed and treatment was begun.

How Do You Know if You or Someone You Care About Has BDD?

It is important to remember that BDD is not a rare disorder, only an underrecognized one. It affects children, adolescents, and adults, and it affects men as well as women.

How do you know it's really BDD? Diagnosing BDD can be challenging because sufferers often keep their symptoms secret due to embarrassment and shame. Often their roommates, friends, professors, and families may not realize that a serious yet treatable problem is occurring. People with BDD often worry that other will consider their concerns superficial and vain, thereby making themselves feel worse for having the symptoms of this disorder. Others may see the BDD sufferer's concerns as attention getting and will become irritated with them. In addition to being underdiagnosed, BDD can be misdiagnosed by professionals, partially because it is not yet widely recognized and also because BDD sufferers are often reluctant to discuss their symptoms.

Body dysmorphic disorder consists of a preoccupation with a nonexistent or minimal defect in appearance. Some people with BDD do have a minor physical defect, like mild acne or slightly thinning hair. But the flaw is only slight. The person with BDD, however, considers the flaw to be noticeable, unattractive, even ugly. In addition, the appearance preoccupation must cause significant distress or impairment in social, academic, occupational, or other important areas of functioning.

What are the preoccupations or obsessions of BDD like? BDD sufferers commonly think about their appearance problem for at least an hour a day, sometimes for much more. Often they cannot resist or stop their thoughts even though they try hard to do so. BDD preoccupations can focus on any body part and often focus on more than one aspect of appearance. Commonly, BDD sufferers focus on their face or head, most frequently their nose, hair, or facial skin, but any body area(s) can be affected. Whereas some people with BDD realize they look worse to themselves than they do to others, others with BDD are completely convinced that their view of their defect is accurate. BDD sufferers often feel that other people take special notice of their perceived defect; for example, stare at it, laugh at it, or talk about it.

If you glance in the mirror a few times before you go out on a date, is this a compulsive behavior associated with BDD? Most likely not. Most people with BDD perform one or more repetitive, time-consuming rituals that are usually aimed at improving, hiding, or further examining their perceived flaw. This often takes the form of looking in mirrors or reflective surfaces. But the behavior goes beyond normal checking of one's appearance. In fact, some sufferer's spend a dangerous amount of time looking in the rearview mirror while driving instead of looking at the road. Similarly, people with BDD may look at compact mirrors during lectures, causing them to miss some of the lecture. Others sneak glimpses of their reflection in store windows as they're walking along the street, causing them to seemingly ignore friends or walk into things. Individuals with BDD also frequently compare themselves to others, groom themselves excessively, or try to hide their perceived defect through camouflage such as makeup, hair, body position, or clothing. Some people with BDD repeatedly ask friends or family members for reassurance that they look okay, or they may try to convince others of their supposed ugliness. This can be very frustrating for roommates, friends, and family members, because the BDD sufferer usually isn't reassured, at least for a very long, no matter how much reassurance is provided.

What Are the Consequences of BDD?

Some people with BDD function relatively well, whereas others can be incapacitated by their symptoms. Areas that can be affected to a greater or lesser degree include the ability to work, or do school work, manage a household, attend school, and function socially. Sometimes functioning is so poor that the person has no alternative but to drop out of school or stop working. Relationship and peer problems are common. Some individuals with BDD have no friends or only a few friends, avoid dating and other types of socializing. Some drop out of significant relationships because of their symptoms. Down time in the dorm or sorreity/fraternity may be avoided because of embarrassment or shame about their appearance. Ironically, others are apt to misinterpret this behavior as rejection, thinking that the BDD sufferer really doesn't want to be with them. Severely ill individuals tend to confine themselves to their room or home, finding it especially difficult to go out to public places such as beaches, clothing stores, or classes. Many people with BDD become depressed, and some even consider suicide. Levels of distress and functioning in BDD span a broad spectrum from those who function relatively well yet struggle to do so, to those who function below their potential despite their efforts, to those who are severely debilitated by their symptoms and may even be driven to commit suicide.

What Happens to BDD Over Time?

BDD usually begins during early adolescence, although it can occur in children and can also begin in adulthood. It appears to be a waxing and waning disorder that is generally chronic. Other disorders can co-exist with BDD and may be more obvious to a roommate or casual observer than the BDD itself, which may be hidden. These disorders include depression, social phobia, and obsessive compulsive disorder, which may be closely related to BDD.

How Do You Know If You Have BDD?
What Are Some of the Cues to the Presence of BDD?

Some clues to the presence of BDD are the following. They aren't required for the diagnosis, but may be present.

Frequently comparing your appearance with that of others; scrutinizing the appearance of others

Often checking your appearance in mirrors and other reflecting surfaces

Camouflaging some aspect of your appearance with clothing, makeup, a hat, hair, your hand, or your posture

Seeking surgery, dermatology treatment, or other medical treatment for appearance concerns when doctors or other people have said such a treatment isn't necessary

Questioning others: seeking reassurance or attempting to convince others that you don't look right

Excessive grooming (e.g., combing hair, shaving, removing or cutting hair, applying makeup)

Avoiding mirrors

Frequently touching the defect

Picking your skin

Measuring the disliked body part

Avoiding having photographs taken

Excessively reading about the defective body part

Exercising or dieting excessively

Avoiding social situations in which the perceived defect might be exposed (e.g., going to classes, participation in class discussions)

Feeling very anxious and self-conscious around other people because of the perceived defect
The following questionnaire, called the BDDQ, is a useful screening questionnaire for the presence of BDD.

This questionnaire asks about concerns with physical appearance. Please read each question carefully and circle the answer that is true for you. Also write in answers where indicated.


1. Are you very worried about how you look? Yes No

If yes: Do you think about your appearance problems a lot and wish you could think about them less? Yes No
If yes: Please list the body areas you don't like:

Examples of disliked body area include: your skin (for example, acne, scars, wrinkles, paleness, redness); hair; the shape or size of your nose, mouth, jaw, lips, stomach, hips, etc.; or defects of your hands, genitals, breasts, or any other body part.

(NOTE: If you answered "No" to either of the above questions, you are finished with this questionnaire. Otherwise please continue.)

2. Is your main concern with how you look that you aren't thin enough or that you might get too fat? Yes No

3. How has this problem with how you look affected your life?

Has it often upset you a lot? Yes No
Has it often gotten in the way of doing things with friends or dating? Yes No

If yes, describe how:

Has it caused you any problems with school? Yes No

If yes, what are they?

Are there things you avoid because of how you look? Yes No

4. How much time a day do you usually spend thinking about how you look? Please circle one.

a) Less than 1 hour a day
b) 1 - 3 hours a day
c) More than 3 hours a day

You're likely to have BDD if you give the following answers on the BDDQ:

Question 1: Yes to both parts
Question 3: Yes to any of the questions
Question 4: Answer b or c

What Should I Do If I or Someone I know Has BDD?

The first thing to do is to realize that you are not alone; many individuals with BDD suffer in secret and in silence. Many BDD sufferers feel they must simply live with their problem because they see it as self-centeredness or shallowness and also because they're too embarrassed or ashamed to seek treatment or even tell close friends, families, roommates, and significant others about their difficulties. Often they feel they are the only person in the world with these thoughts. Ironically, nothing could be further from the truth. Many individuals, including many college students, suffer from BDD. It is also important to maintain hope. Treatments are available for BDD, and we are learning more about it every day. It is very important to realize that help is available.

What Are Some Treatments for BDD?

Although we don't yet know what causes BDD, we hypothesize that a neurobiological brain problem - a "chemical imbalance" - is necessary for BDD to occur. It is possible that BDD involves malfunctioning of a brain chemical (neurotransmitter) called serotonin, which may also be involved in obsessive compulsive disorder. It is also possible that psychological and social factors may contribute to BDD, but more research is needed to shed needed light on exactly what causes and maintains BDD.

Many people with BDD seek nonpsychiatric treatment, including dermatologic treatment and even surgery. Some very desperate BDD sufferers even attempt to do surgery on themselves. It appears that most people with BDD do not find relief from such treatments and in fact may end up disliking their appearance even more.

Serotonin reuptake inhibitors (SRIs) are a class of medications that appear to be effective for many people with BDD. These medicines are also used as antidepressants, and side effects, if they occur, are usually well-tolerated. These medications appear to work by influencing serotonin activity in the brain. The SRIs which are currently available in the United States are fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and clomipramine (Anafranil). Preliminary studies as well as clinical experience suggest that these medications are often effective for BDD. When people respond to an SRI they find that they spend less time obsessing about their appearance, and it's often easier to push the thoughts out of their mind and think about other things. They often feel as if they have regained some control of their mind. BDD behaviors become easier to resist and overall functioning improves. It becomes easier to be around people, attend classes, and have a more normal social life. The anxiety, depression, and suicidal thinking that can occur with BDD also diminish with response to an SRI. There is often improvement in body image and self-esteem as well.

It can take as long as three months (or occasionally longer) for the medication to work, and relatively high doses may be needed. Improvement of symptoms usually occurs gradually, so it's important to be patient while waiting for the medication to work. If one type of SRI is not effective, another may be and is worth trying. Occasionally other medications are used along with an SRI to augment its effectiveness. In more treatment resistant cases, it's always a good idea to seek consultation from a psychiatrist with expertise in prescribing medication and expertise in treating BDD or obsessive compulsive disorder.

Cognitive-behavioral therapy (CBT) is also used to treat BDD. For more severe symptoms, CBT should be used in combination with medication. CBT is best used when the person with BDD recognizes to at least some extent that their view of their defect is exaggerated. Cognitive therapy targets the ways in which distorted, unrealistic, or negative beliefs and attitudes affect behavior. With the therapist's guidance, the patient changes his or her problematic beliefs and creates alternative and more realistic beliefs and attitudes. Specific behavioral techniques known as exposure and response prevention, are also used. Exposure consists of deliberately confronting a feared or avoided situation (for example going to a party that you're fearful of attending). The more exposure is done, the easier it gets. Response prevention consists of resisting any compulsive, camouflaging, or reassurance seeking behaviors (e.g., avoiding excessive beauty routines by throwing out makeup and other beauty products). Although CBT appears to often be effective for BDD, most therapists aren't trained to provide this treatment.

Other treatments for BDD include family behavioral treatment, self-help groups, and support groups, all of which can be very useful as adjunctive treatments for BDD. No other treatments currently available seem to be effective for BDD. Supportive psychotherapy serves to create a positive environment in which to apply other therapeutic techniques, but doesn't seem to work by itself. Other psychotherapeutic approaches (for example, insight-oriented psychotherapy, diet, and natural remedies) have not been shown to be effective for BDD.

How Can I Help a Friend or Family Member Who May Have BDD?

There are several key ways in which you can help a person you know who may have BDD:

Don't simply reassure the person. Body dysmorphic disorder is a serious psychiatric condition that goes well beyond vanity and is not generally grown out of by simply waiting long enough. So simply reassuring your roommate or significant other not to worry, or telling them that things will get better on their own, is unlikely to be true and may raise false hopes in the BDD sufferer as well as keep them from seeking appropriate treatment.

Don't get into arguments or discussions about how they really look. In the process of trying to convince your classmate, friend, or partner that their appearance is fine, conflict, frustration and helplessness unfold. Remember, you're asked to respond rationally to something that isn't rational. It isn't productive. Also, telling your roommate to try harder to stop worrying isn't helpful. It usually alienates them and makes them feel you don't understand how real their concern is.

Don't help with BDD related behaviors. Encourage BDD sufferers to cover or take down mirrors. Don't provide reassurance. Don't pay for new clothing for them that isn't necessary. Don't pay for repeated surgeries. Don't participate in their grooming or examining rituals (e.g., don't hold special lights to provide them a better view of their defect). It can be very difficult not to participate in these behaviors, but it's best to explain to the BDD sufferer that you understand how distressed they feel and that you're helping them control their behavior by not taking part in their rituals. It's crucial to be consistent and to not appear cruel or punitive when doing this.

Do support healthy normal activities. Always urge participation in school, extracurricular, or family events. Remind the person with BDD that the focus is not going to be on them and that once fears are faced they often diminish.
Do encourage BDD sufferers to get professional help so they will worry less, be less distressed, and function better. Encourage the person to stay on medication (if one is prescribed) and to discuss any side effects or problems with their psychiatrist. Tell them to remember that individuals with body dysmorphic disorder can and often do get better. Encourage them to seek further treatment even if past treatment hasn't been successful by telling them that more is being learned about BDD and its treatment every day. Some treatments available now weren't available in the past. Help them to seek a professional with expertise in treating BDD or obsessive compulsive disorder.

What Resources Are Available to Learn More About BDD?


The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder, by Katharine Phillips, M.D. Oxford University Press, New York 1996. This book, written for both professionals and the public, is the most comprehensive source on BDD.

Learning To Live With Body Dysmorphic Disorder, by Katharine A. Phillips, M.D., et. al. Obsessive-Compulsive Foundation, June, 1977.

References for articles from professional journals can be obtained through Medline and Psychlit computerized databases.


The Obsessive-Compulsive Foundation, Inc.
Address: P.O. Box 70, Milford, CT 06460-0070
Telephone: (203) 878-5669
Information Line: (203) 874-3843
Fax Line: (203) 874-2826

The OCF publishes two newsletters: The OCD Newsletter and Kidscope

Madison Institue of Medicine
Address: Madison Institue of Medicine, 7617 Mineral Point Road Suite 300, Madison, WI 53717
Telephone: (608) 827-2470


If you have BDD and live in Southeastern New England you may be eligible to participate in one of our research studies. Please contact us at:

Butler Hosptial, 345 Blackstone Boulevard, Providence, Rhode Island 02906
Telephone: 401 - 455 6466
Fax: 401 - 455 - 6436
Website: http://www.butler.org/bdd.html
Email: katharine_phillips@brown.edu

All pages at the domain www.worldcollegehealth.org © copyright The In Remembrance Project. and Worlde College Health. All rights reserved.


Bron : http://www.ocdla.com/bodydysmorphicdisorder.html

The primary distinguishing feature of Body Dysmorphic Disorder (BDD) is an obsessive preoccupation with a perceived defect in one's physical appearance. BDD obsessions may manifest as excessive, disproportionate concerns about a minor flaw, or as recurrent, anxiety-provoking thoughts about an entirely imagined defect. The obsessions are most frequently focused on the head and face, but may involve any body part. BDD goes beyond normal concern with one's appearance, and may significantly impair academic and professional functioning, as well as interpersonal relationships. In extreme cases, an individual may completely shun any contact with people in an effort to avoid having the defect being observed by others.

Common BDD obsessions involve:

Moles and freckles being too large or noticeable
Minor scars or skin aberrations
Too much facial or body hair
Too little hair on head
Size and/or shape of genitalia
Breast size
Muscles being too small
Overall size, shape and/or symmetry of the face or another body part
Common BDD compulsions include:

Repetitive checking of a minor or imagined flaw in mirrors
Avoidance of mirrors
Avoidance of having picture taken
Repetitive grooming activities such as shaving, combing hair, etc.
Repetitive checking, touching and/or measuring of a minor or imagined defect
Wearing excessive make-up to camouflage a minor or imagined flaw
Wearing certain clothes to camouflage a minor or imagined defect
Multiple medical visits, especially to dermatologists
Multiple medical procedures in an effort to eradicate a minor or imagined flaw
As demonstrated above, BDD has obsessive-compulsive features that are quite similar to those of OCD. In fact, one recent study found that 24% of those with BDD also had OCD. Perhaps the most significant similarity linking the two disorders is the cyclical process by which the symptoms of both increase. To learn more about this process, click here.

Because of these many similarities, the same Cognitive-Behavioral Therapy (CBT) techniques that are so effective in treating OCD are also employed in treating BDD. The primary CBT technique used in treating both of these conditions is Exposure and Response Prevention (ERP). For more information on this treatment, click here.

If you are experiencing any of the above symptoms, or would like more information about BDD and its treatment, you can call OCDLA directly at (310) 335-5443, or click here to email us. If you live outside Southern California, we recommend that you contact a licensed Cognitive-Behavioral therapist in your local area.

Please note that the above is not meant to replace a complete and thorough evaluation by a licensed Cognitive-Behavioral therapist or other qualified mental health professional. As with OCD, some individuals with BDD may benefit from medication, and may therefore require a psychiatric evaluation. Likewise, a psychiatric assessment may be necessary to differentiate between BDD and other psychological conditions. If a psychiatric evaluation is indicated, OCDLA can refer you to a qualified psychiatrist in the Los Angeles area. Furthermore, it is imperative to make the distinction between BDD and other medical conditions. For this reason, a medical examination may be necessary.


Bron : http://www.bio-behavioral.com/BDD.html

Body dysmorphic disorder (BDD) is a condition that involves an intense preoccupation with a particular aspect(s) of physical appearance in a normal appearing person. Although individuals can become preoccupied with any aspect of their appearance, concern with facial features is the most common. Patients may complain, for example, that their nose is too large nose, their hairline is receding, or they have facial blemishes.

BDD first appeared in the scientific literature in 1886 when a researcher by the name of Morselli provided a detailed description of the disorder. He conceputalized BDD as a subjective feeling of ugliness terming it "dysmorphophobia." It was later referred to as "imagined ugliness." The current psychiatric diagnostic manual (DSM-IV) provides the following criteria for diagnosis of BDD:

Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
The preoccupation causes clinically significant distress or impairment in social, occupational or other important areas of functioning.
The preoccupation is not better accounted for by another mental disorder, such as anorexia nervosa.
Recent research has provided evidence that BDD can be conceptualized as an "obsessive-compulsive spectrum disorder." The obsessive-compulsive spectrum refers to a series of major psychiatric conditions defined by the presence of obsessions and compulsions. Obsessions are intrusive ideas, thoughts, or images that cause much anxiety and distress. Compulsions are repetitive behaviors or mental acts performed to reduce the anxiety produced by obsessions. In the case of BDD, patients experience intrusive negative thoughts related to their appearance and perform many behaviors in order to cope with the imagined defect, such as repeated mirror checking. Other disorders that fit into the spectrum include: obsessive compulsive disorder, trichotillomania, compulsive orective mutilative snydrome, self mutilation, hypochondriasis, anorexia nervosa, and Tourette's snydrome.


The essential symptom of BDD is the presence of repetitive and intrusive thoughts about one's physical appearance. The preoccupation interferes with daily living and is very distressing to the individual. These repetitive thoughts often lead to certain behaviors meant to disguise or cope with the imagined defect. Common behaviors include deliberate camouflaging of the defect using: hats, scarves or other articles of clothing as well as make-up or other cosmetic products. They may alter their body posture or avoid coming in close physical contact with family, friends, and even strangers.

Individuals with BDD also tend to spend many hours examining the body part in mirrors and shiny surfaces or may go to great lengths to avoid mirrors. Often, the same individual will alternate between avoiding mirrors and then examining themselves for hours. BDD patients may constantly questions family or friends about their appearance, with the purpose of seeking reassurance. They may repeatedly consult with medical professionals, such as cosmetic surgeons or dermatologists in order to find ways to improve their appearance. Repeated cosmetic surgery, such as rhinoplasty, is quite common. Researchers have observed that compulsive skin picking can also occur as a symptom of BDD. Some individuals may use their nails or tweezers to remove supposed blemishes or hairs on their face and body. Ironically, repeated skin picking can lead to actual permanent scars.

Avoidance of social situations is also quite prevalent. They may avoid parties or other events. Individuals with BDD may prefer to go outdoors only when it is dark outside so that their "defect" is not as visible to others. It is possible for the individual to eventually become housebound, without appropriate treatment. All of these behaviors interfere significantly with the person's daily functioning.

Most patients belief about their defect is quite strong. Family and friends are usually unable to convince the individual that their appearance is within normal limits. Often the belief is so strong that it can be classified as an "overvalued idea." Professionals at our Institute have developed an interview based questionnaire ("The Overvalued Ideas Scale") to evaluate the strength of the belief.

Individuals with BDD are usually very secretive about their preoccupation. They often feel a sense of shame or embarrassment or think that others will perceive their behavior as vain or silly. Often even treating medical professionals are unaware about the presence of BDD unless a thorough interview is conducted, with specific questions about BDD symptoms. Usually, the person will present with depression and low self-esteem.

It is important to note that research has found that up to 40% of individuals with BDD think about or attempt to commit suicide.

BDD is often accompanied by other psychiatric conditions, such as depression, social phobia, or other anxiety disorders.


BDD may affect up to 2% of the United States population. The ratio of males to females appears to be equal. BDD seems to begin in adolescence. Research at our Institute and other centers indicates that the age of onset is between 14 and 20. Cases that begin at an earlier or later age are not uncommon.

Since BDD has only recently gained the attention of researchers, no one specifically knows what causes it. BDD is commonly viewed as a medical illness in which certain chemicals (neurotransmitters) in the brain are influenced. Serotonin is thought to be the neurotransmitter most likely to be involved in BDD. Some researchers suggest that BDD is an abnormal response to the physical changes that occur in adolescence. The focus on the body continues into adulthood due to constant attention on physical appearance which leads to avoidance of social situations. Traumatic incidents, such as being teased about one's appearance, comments by acquaintances, repeated criticism by family members, and abuse have also been thought to trigger the disorder.


Current research conducted at our Institute indicates that techniques used to treat obsessive compulsive disorder (OCD) are also effective for BDD. Cognitive therapy and exposure and response prevention (ERP) combined with medication are the current treatment of choice.

One study conducted at the Institute found that four out of five patients showed significant improvement after undergoing a combination of cognitive therapy and ERP. Intensive treatment, with sessions held more than once a week, were the most beneficial.

Another one of our research projects found that ERP and cognitive therapy was effective in 12 out of 17 patients who also had personality disorders. Treatment consisted of intensive 90 minute sessions five times a week for four weeks. All of the subjects met criteria for at least one personality disorder and 13 out of the 17 had four or more. Treatment sessions consisted of 60 minutes of ERP and 30 minutes of cognitive therapy. No relationship between treatment response and number of personality disorders was found.

Cognitive therapy involves challenging and altering faulty thinking patterns. It is believed that faulty beliefs lead to negative emotions and behaviors. In cognitive therapy, patients learn to first identify faulty thinking patterns, challenge these thoughts and finally derive more constructive beliefs. It is believed that constructive thoughts lead to more positive emotions and behaviors. Common cognitive distortions include: "I must be perfect," "I must be noticed," "The only way to feel better is to look better," as well as "If I am not beautiful, then I must be ugly." It is the experience of our clinicians that cognitive therapy is more effective when done at the onset of treatment.

ERP is the specific behavioral technique implemented at our facility for BDD and numerous other disorders. ERP involves exposing patients to situations frequently avoided or feared while preventing the person from engaging in compulsive behaviors that artificially reduce the anxiety. Patients willingly engage in ERP sessions and are exposed to anxiety provoking situations at their own pace.

The following is an example of ERP treatment for a BDD patient with the belief that his/her nose is too large: The therapist first makes a list of situations avoided or feared by the individual from least to most anxiety provoking. This list is referred to as an "anxiety hierarchy." Common situations include: attending a party, going on a date, sitting very close to another person on public transportation, having photographs taken, and brightly lit places such as department stores. The therapist then takes the individual to these places and encourage him/her to interact in the situation while at the same time preventing rituals, such as mirror checking or hiding his/her nose. Patients are encouraged to stop all rituals outside of sessions as well. Often, mirrors are covered up in the home and cosmetic products are thrown out. Between session homework assignments are given for further exposure exercises. The goal of ERP is for the individual to experience a natural reduction in anxiety in previously feared situations.

The class of medications called "serotonin reuptake inhibitors" had been found to be effective. It is generally recommended that medication should be accompanied by cognitive therapy and ERP for the maximum benefit.

The following medications are most commonly used to treat BDD:Prozac,Anafranil,Zoloft,Paxil,Luvox

Clomipramine More Effective Than Desipramine For Body Dysmorphic Disorder

Bron : http://www.pslgroup.com/dg/13ea96.htm

LOS ANGELES, CA -- October 26, 1999 -- The drug clomipramine is more effective than desipramine in the treatment of body dysmorphic disorder (BDD), a disorder in which a person is preoccupied with an imagined or slight defect in their appearance. These results are presented in an article in the November issue of the Archives of General Psychiatry, a member of the JAMA family of journals.

Eric Hollander, M.D., and colleagues from the Mount Sinai School of Medicine, in New York, randomized 29 patients to initially receive either clomipramine or desipramine for treatment of BDD for the first eight weeks of the drug trial. The participants then "crossed over" to use whichever drug they had not yet used for the remaining eight weeks of the trial.

The trial was double-blinded (neither the participants nor the psychiatrists and psychologists who evaluated the participants were aware of which treatment the participants were receiving).

Dr. Hollander presented the results of the study today at the American Medical Association’s 18th Annual Science Reporters Conference at the University of California at Los Angeles.

The researchers found that clomipramine, a serotonin reuptake inhibitor, was significantly more effective than desipramine, a norepinephrine reuptake inhibitor, in reducing the patient’s obsessive preoccupation with perceived body defects and their repetitive behaviors in response to this preoccupation as well as reducing overall BDD symptom severity. The researchers also found that clomipramine was more effective than desipramine in improving functional disability.

For people with BDD, the most common perceived flaws in appearance are facial, but persons with BDD may also have a preoccupation with other body parts. Citing other research the authors note: "BDD results in severe distress, impairment in social and occupational functioning and high rates of hospitalization, suicidal ideation and suicide attempts. ...

Attempting to examine, mask or change their appearance, patients perform compulsive/repetitive behaviors such as frequent mirror checking, excessive grooming or skin picking. Up to 50 percent of patients with BDD turn to surgical procedures in futile attempts to correct perceived defects."

The authors note that BDD shares similar features with obsessive-compulsive disorder (OCD), especially obsessive and intrusive thoughts and compulsive and repetitive behaviors, as well as the age range in which the disorder typically begins (during the teenage years). They add that other studies have indicated that up to 12 percent of psychiatric outpatients may have BDD.

"The positive findings of this first controlled study in BDD are a significant initial step in establishing the efficacy of clomipramine in the treatment of this debilitating disorder, even among delusional patients," the authors write.

The effect of the treatments was independent of the presence or severity of other coexisting psychological disorders, such as OCD, depression or social phobia, according to the authors. The researchers also studied whether there was a difference between patients with BDD who were delusional and those that were not. "Fixity [how strongly held the beliefs were by the patient] of BDD beliefs did not limit treatment outcome; while receiving clomipramine delusional patients improved at least as much as nondelusional patients and perhaps more," the authors write. "This is of clinical importance, suggesting that delusional patients may not require neuroleptic treatment [treatments used to treat psychosis] and thus might be spared possible adverse effects associated with long-term neuroleptic use."

This study was supported in part by grants from the Food and Drug Administration, Washington, D.C., the Seaver Foundation, New York, and the National Institutes of Health, Bethesda, Md., to the Mount Sinai Clinical Research Center.

While clomipramine and desipramine are both tricyclic antidepressants, they afect the central nervous system differently. Clomipramine is a serotonin reuptake inhibitor and desipramine is a selective norepinephrine reuptake inhibitor.

(Arch Gen Psychiatry. 1999;56:1033-1039)

A Scottish hospital has launched an inquiry after a surgeon agreed to remove healthy limbs from patients suffering from a psychological disorder. BBC News Online looks at the condition.

Bron : http://news.bbc.co.uk/1/hi/health/medical_notes/625913.stm

What is Body Dysmorphic Disorder?

People with body dysmorphic disorder (BDD) worry about their appearance, believing, for example, that their skin is scarred, that they are balding or their nose is too big. They refuse to believe reassurance from others that their appearance is not abnormal.

The condition's severity varies - some people can manage it, others have their lives ruined by the disorder. There have been cases of suicide linked to BDD.

Dr Ian Steven, a psychologist in Edinburgh, said: "People become fixated or concerned with particular areas of their body and have difficulty accepting that there is no illness present.

"Most people resolve problems by going to see a doctor or get issues addressed by expert specialists, getting it clarified that there is nothing wrong with the part of the body they are concerned about."

He said in the Falkirk cases, "these people have had great difficulty accepting the correctness of the diagnoses of their practitioners".

He said the condition could be described as a very severe form of hypochondria.

What are the symptoms of BDD?

People with BDD constantly compare their appearance with people around them, and check their own appearance in mirrors. They use clothing, make-up or other disguises to cover up the perceived flaw.

In more extreme cases they seek surgery, dermatological treatment, or, as in the cases under investigation at Falkirk Royal Infirmary, amputation, to remove what they see as being wrong with their bodies.

Frequently touching the perceived defect, picking at skin, and excessive dieting or exercise may be signs of the disorder.

Some sufferers regularly seek confirmation about the supposed flaw from other people and research the area extensively. But they will often avoid social situations where the perceived defect might be exposed.

How many people suffer from the disorder?

Dr Katharine Phillips, a psychiatrist based at Butler Hospital in Rhode Island, USA, estimates that as many as one in 50 people may have the disorder, most of them men and women in their 30s.

Dr Steven said he considered it to be "very rare", though there are many people suffering from obsessions about their bodies "in minor ways".

Why is the condition not diagnosed?

Many sufferers are extremely secretive about the condition and do not reveal the symptoms to others.

Many health professionals are not aware that BDD is a psychiatric disorder that can be treated. Sufferers often see a dermatologist, plastic surgeon, or other doctor rather than a mental health expert, though these treatments are unhelpful.

The condition is easy to trivialise.

What can be done to tackle the disorder?

Psychiatric treatment, including medication and cognitive-behavioural therapy can be effective in decreasing symptoms and the suffering it causes.

Medications, including selective serotonin reuptake inhibitors (SSRIs) and fluoxetine (Prozac), can relieve obsession and decrease distress and depression, allowing the sufferer to function normally.

Cognitive-behavioural therapy can also help reduce compulsion. Counselling alone is not said to be as effective.

Dr Steven said: "As a psychologist, the first approach would be to find out the origins of the problem and why the fixation exists.

"You would then be working through a system of a cognitive approach, to help the individual come to terms with what their concerns are."

Body Dysmorphic Disorder: The “Ugly” Disease

Bron : http://www.efit.com/servlet/article/789.html

(Nutricise) — Everybody feels less than model-perfect some days, but this illness is far beyond what's normal

How you look, or rather, how you think you look, can affect the way you feel about yourself. There's probably a reasonable connection between the two for most people. For example, you may not feel so confident about doing an oral presentation if you feel that you're having a bad hair day, or maybe you get bummed out when you've got a couple of blemishes. On the flip side, if you find yourself constantly being concerned that everyone is gawking at your hair because it's unflattering in some way, or if you're worried people's attention is focused on your less-than-perfect complexion or your weight that you cancel school-related activities and dates with friends, you're in dangerous psychological territory.

Body dysmorphic disorder (BDD), often called imagined ugliness, is a preoccupation with a defect in one's appearance (weight, complexion, hair, face and legs are the most common fixations)—often an imperfection that exists only in the person's mind. As many as 5 million people in the United States may have BDD, and while the disorder strikes both men and women of any age, adolescence may be the most common time of onset—news that may not be all that surprising considering that high school is often the first time in a person's life when attractiveness equals popularity and acceptance.

In an environment in which it seems like you have to be Britney Spears's twin to get a prom date, how much stressing over your looks is normal and how much constitutes a real psychological problem? "There's no clear division," explains James Rosen, professor of psychology at the University of Vermont, "but you begin to have a problem when you attach more importance to your appearance than is realistic. If you think that if you don't look perfect nobody could ever care about you, or you think that people are repulsed by you, that's not normal. Looks do make a difference, at least initially. To a degree we all judge a book by its cover so to speak, but when people come to choosing their friends, it's usually based on a personality and a sense of values."

The symptoms of BDD can range from mild to very severe. In its most extreme cases, BDD can "completely destroy lives," says Katharine Phillips, M.D., author of The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (Oxford University Press, 1996). She tells of one extreme situation involving a young woman who'd been diagnosed with BDD during high school and had grown increasingly worse over the years. She lived with her parents and hardly ever left her bedroom; when she did, she covered her face with a veil.

Certainly not every case of BDD is so severe: Some teens even may function so well that their families don't recognize that anything is wrong, says Phillips. "They may be turning invitations down and pulling out of social circles a little bit."

To someone with a healthy self-image, though, even the mildest symptoms are shocking. For example, in a recent study by Phillips and other doctors specializing in the disorder, many participants spent all their time worrying about the defects they felt they had. They could think of nothing else. The disorder creates a vicious cycle. Most people with BDD tend to withdraw from social activities, but withdrawing from others because you think they won't accept you usually only worsens the problem. For example, if you won't talk to guys because you feel as if they're staring at your body and wondering why it's not more like Christina Aguilera's, you may inadvertently start sending out the vibe that you're unfriendly—which will make guys stay away from you, which will confirm your fears that you don't measure up and that therefore you're undesirable.

So what should someone with BDD do? For many, facing their fears is the way to go, says Rosen. "It's a little like overcoming a phobia of driving after being in a car accident," he says. "You're not going to get over that fear until you get behind the wheel again."

Some sufferers of BDD are beyond the point of helping themselves. Several studies have suggested that antidepressant or anti-anxiety drugs are effective for many patients with severe symptoms. Often people think that cosmetic surgery is the answer; most of the time, however, it's not, because the problem is actually in your mind. "I usually advise against it," says Phillips. "Surgery is irreversible, and most people with BDD usually feel like it didn't work anyway."

If you think you may have BDD, you should talk with a friend or a mental health practitioner about it. If you think a friend may be suffering—for example, she won't play sports or go to the beach because she believes her legs are too bulky—confront her. It may be difficult, but ultimately it could help. Left untreated, BDD usually only gets worse.

About Body Dysmorphic Disorder

Bron : http://www.aboutourkids.org/articles/about_bdd.html

Real life stories
What are the symptoms?
Who is likely to have it?
Why does it happen? How is it treated?
Questions and answers
About the author
References and related books
AboutOurKids related articles

by Naomi Weinshenker, M.D.

Many of us spend a lot of time and effort on our appearance. We wear makeup, work out at the gym, buy flattering clothes and style our hair, all done in hope of looking more attractive. Individuals with Body Dysmorphic Disorder (BDD) are beset by a more extreme version of these normal appearance concerns. BDD is characterized by a time-consuming and potentially disabling preoccupation with imagined or slight defects in one's appearance or excessive concern about a slight physical anomaly. To meet the criteria for this diagnosis, the preoccupation must cause significant distress or impair school, personal or social functioning. Although virtually any body part can become the source of preoccupation, BDD most commonly involves the eyes, ears, nose, skin, chin, jaw or other facial features. Although we don't know what causes BDD, most likely there are multiple sources including biological, psychological and sociocultural factors. Both medication and cognitive/behavioral therapy have been helpful in moderating the symptoms.

Real life stories
For 17-year-old James, the simple act of looking in a mirror is torture. Ever since a friend made a casual comment about his appearance, James has been obsessed with the size and shape of his nose. "It's just not right... it just doesn't fit my face" he will state. James is unable to be reassured that there is nothing objectively wrong with his nose and will spend at least an hour per day checking himself in various reflections. He has begun to consult with cosmetic surgeons about the possibility of rhinoplasty.

"I wish I could convince my parents to take me to a plastic surgeon" said 15-year-old Kristin. She is preoccupied with her "large" jaw, "small" breasts and "uneven" skin and will ask her mother whether she looks okay at least a dozen times per day. She has begun to use heavy makeup and has also started wearing long sleeves and pants at all times in order to cover her skin. Kristin's appearance concerns are so time-consuming and distressing that she has ceased to spend time with her friends and has dropped her extracurricular activities.

Both James and Kristin have Body Dysmorphic Disorder.

What are the symptoms?
The defining features of Body Dysmorphic Disorder are a distressing and time-consuming preoccupation with an imaginary defect in one's appearance, or excessive concern about a slight physical anomaly. This preoccupation causes significant distress or impairs school or work, personal or social functioning. Although virtually any body part can become the source of preoccupation, BDD most commonly involves the eyes, ears, nose, skin, chin, jaw or other facial features. Other areas of concern include hands, feet, breasts and genitals. People with Body Dysmorphic Disorder are ashamed of their "defect" and invent elaborate means to hide their deformity from the world. Camouflaging behaviors include excessive hair combing and hair removal, ritualized application of makeup and avoidance of situations that might expose the perceived defect. Anxiety, shame and secondary depression are frequent consequences of this disorder. In one case series of individuals with BDD, 30% were so impaired as to remain housebound.

The most frequent co-occurring psychiatric disorders are obsessive-compulsive disorder, social anxiety disorder and depression. Suicidal thinking and gestures are, unfortunately, not uncommon consequences of BDD.

Who is likely to have it?
Body Dysmorphic Disorder often begins as early as adolescence and may remain undiagnosed for years. It is rare for children under 12 to be diagnosed with BDD. Although there have been no formal studies of the frequency of BDD in the general population, it is estimated to affect 1-2 % of the United States population. If BDD were simply an extreme form of normal attention to appearance, it would probably be much more common in females because women show more obvious outward signs of appearance concerns. However, BDD appears to affect roughly equal numbers of males and females. Research to date suggests that although the symptoms echo normal appearance concerns, BDD is far more complex and serious a disorder.

Why does it happen?
At this time, theories about the cause(s) of BDD are speculative. Most likely there are multiple factors, including biological, psychological and sociocultural, that contribute to its etiology. Neurochemical factors, such as abnormalities in the brain chemical serotonin, may make some people more likely to express the symptoms of BDD. However, psychological factors such as teasing about one's appearance during childhood, family's or peers' emphasis on appearance or trauma or sexual abuse might also be risk factors for the expression of symptoms. Finally, media messages about appearance might worsen the condition in some vulnerable individuals with BDD.

How is it treated?
Psychopharmacology : The antidepressants known as SSRIs (selective serotonin reuptake inhibitors) are the cornerstone of medication treatment for Body Dysmorphic Disorder. Examples of SSRIs include Prozac, Zoloft and Paxil. The SSRIs are a type of antidepressant used successfully in the treatment of both depression and obsessive-compulsive disorder. People who respond to an SSRI generally experience improvement in several ways. They spend less time thinking about the defect and the thoughts are less intrusive and painful. Compulsive behaviors, such as checking or camouflaging, often diminish. Patients often report that associated anxiety and depression have lessened. Ultimately, self-confidence and self-esteem are enhanced.

Psychotherapy: Although research is still in the early stages, cognitive-behavioral therapy (CBT) appears to be another good treatment for Body Dysmorphic Disorder. A particular type of CBT known as Exposure and Response Prevention has been shown, thus far, to be the most useful type of therapy for BDD. Exposure consists of having the individual expose the physical defect in feared and/or avoided situations (i.e. school or social situations) while response prevention involves helping the individual refrain from performing compulsive behaviors related to the defect. The goal is that, over time, anxiety associated with the feared defect and situation will decrease and the associated behaviors will lessen in frequency. This type of therapy is often recommended in addition to medication.

Questions and answers

How do I know if my adolescent has Body Dysmorphic Disorder?
Body dysmorphic disorder can be a secretive condition and may not be immediately recognizable, even to parents or other family members. Adolescents with BDD may spend a lot of time alone in the bathroom; they may appear to be distant and self-preoccupied. Be concerned if your adolescent engages in excessive grooming rituals or asks repeatedly for assurance about appearance yet is unable to be reassured.

How do I respond to my teenager's requests for reassurance about his/her appearance?
Surprisingly, responding with reassurance will only heighten the concerns. Although it may be difficult, it is best to refrain from providing reassurance. Try to avoid commenting directly about the supposed defect; do not encourage visits to the dermatologist or plastic surgeon but instead support psychiatric treatment.

Will an adolescent with Body Dysmorphic Disorder get over it?
BDD appears to be a chronic condition and we don't yet have a good idea of the long-term course of the illness. We don't yet know if adolescents diagnosed with BDD and stabilized on medication will require the medication throughout their adult life or will outgrow the symptoms.

My 14-year-old son refuses to attend family events because of how he thinks he looks - what can I do?
Besides encouraging attendance at such events, the parents of a BDD sufferer should attempt to get the adolescent into psychiatric treatment. The combination of medication plus cognitive/behavioral therapy can be very helpful in allowing your adolescent to attend family and other social situations.

My 16-year-old wants cosmetic surgery. What should I do?
Research to date shows that surgical treatment is not helpful for adolescents and other sufferers with BDD. Individuals who have surgery are usually dissatisfied with the results, or, if satisfied, tend to re-focus their concerns on another part of the body. Remember, Body Dysmorphic Disorder is a psychiatric and not a surgical disorder.

How do I parent a teenager with Body Dysmorphic Disorder?
There are several things parents can do to alleviate their child's suffering. First, take the disorder seriously. Second, avoid reassuring your child that they look okay but instead encourage them to talk openly about their concerns. Third, encourage and support psychiatric treatment and discourage surgical treatment.

About the Author

Naomi Weinshenker, M.D. is Assistant Professor of Clinical Psychiatry, NYU School of Medicine. She is the Director of the Young Adult Inpatient Unit at Tisch Hospital. Her clinical and research interests include Body Dysmorphic Disorder, body image and anxiety disorders.

Behavioral Treatment of Body Dysmorphic Disorder
By Frederick Penzel, Ph.D.

Bron : http://www.homestead.com/westsuffolkpsych/BDD.html

A particular disorder which is believed by many to be a member of the OC family, has been receiving a lot of media attention lately. This disorder is known as Body Dysmorphic Disorder (BDD), also called by some Dysmorphophobia, a term originated in the last century by Morselli. We call it BDD when an individual appears to be strongly obsessed with what they believe to be a defect in their appearance. They tend to believe that some part or area of their body is misshapen, asymmetrical, wrongly sized, or ugly. Typical BDD complaints can include preoccupations with the face (such as scars, spots, veins, discoloration, acne, or the shape or size of the nose, lips, mouth, eyes, etc.), the hair (fears of receding hairlines), or the size and shape of any other body part (such as the hips, abdomen, buttocks, legs, hands, etc.). In some cases more than one body part may be involved, or. the preoccupation can shift from one part to another over time. BDD should not be confused with the more common type of dissatisfaction that many people experience with themselves. Ordinarily, many individuals wish they were taller, that their nose was shaped differently, that their breasts were bigger or smaller, or that their thighs weren't so large. Often others will agree with them, and even suggest that. they do something abut it. In BDD, it is very difficult, if not impossible, to see things the way the sufferer does. BDD sufferers seem to be totally preoccupied with the imagined defect which can be something very specific, or very vague. Often, it may be a defect no one else can see, or it can be something so minor or microscopic that we would judge the person to be grossly exaggerating it. Frequently, the belief in the defect can be so strong it seems to border upon being a delusion.


Individuals with BDD tend to spend much time obsessing about their defect, questioning others, checking it directly or with mirrors, or having others check them. Frequent visits to physicians, surgeons and dentists for treatment or correction of the defect are not uncommon. Sufferers will often gather evidence to prove their ugliness. None of these professionals can help, even though they may be sympathetic and do their best. I know personally of several cases where plastic surgery was performed and BDD symptoms returned as soon as the surgery healed. One woman was completely preoccupied with the shape of her nose, had surgery to her specifications, and after six months returned to the same preoccupation when the swelling disappeared. As mentioned before, the degree of belief in the existence of the defect can be extremely high, almost total at times, and frequently higher than we generally see in OCD, although it can vary from person to person. In most of the cases I have seen, there is also a great deal of anxiety over the idea of having the 'deformity'. Many sufferers seem genuinely tortured. One patient found it so upsetting that it took several sessions and a lot of gradual preparation before we could even mention it in therapy. Individuals with BDD may be depressed because they can not convince others of the problem and not being able to change it no matter what they try. I have sometimes seen other typical CC symptoms along with BDD, many of which frequently include various types of perfectionism and double-checking. Social isolation is also common.


The two major modes of treatment which I normally recommend for BDD are the same as those for OCD medication and behavioral therapy. The fact that medication can help seems to point to a biological basis for BDD. As in OCD, success with medication varies from person to person and the same drugs that seem to help with OCD Anafranil, Prozac, and others, seem to help completely. For instance, it can reduce the thoughts of deformity, but not always completely eliminate them. Also, a lot of the checking and questioning habits can remain, even when thoughts are reduced.


Exposure and response prevention is the primary behavioral intervention. Despite their strong belief in the deformity, there is usually enough doubt that these beliefs can frequently be challenged in therapy. Talk therapy alone will not do the job though. In behavioral therapy, our aims are twofold. First, we aim to reduce anxiety about thoughts of deformity via repeated exposure to the thoughts. By doing this, we can bring about habituation to the thoughts as the person gradually exposes him or herself to the thoughts. Individuals purposefully experience the anxiety until it dissipates. Eventually the thoughts do not produce anxiety and interest in them decreases. This exposure can be done in a variety of ways, including using audio tapes containing the fearful thoughts, having the person wear clothes that remind them of the deformity, having them go into situations where the thoughts can occur, looking at pictures of 'perfect' body parts, reading articles that will bring on the thoughts, etc. Sufferers will frequently ask, "1 already think of it a lot and my anxiety isn't any less; how can this help me?" The answer is that they have not exposed themselves to it on purpose, or for very long, nor have they done it systematically and regularly. Also, when they have experienced the thoughts, they typically don't stay with the anxiety for long. Usually, they try to avoid it by checking themselves, asking others for reassurance, or escaping the situation; somehow this prevents habituation from ever occurring.


Our second aim is to prevent the behaviors just mentioned, that sufferers use to reassure themselves and terminate the anxiety. Homework for the response prevention part of the treatment can typically include such things as not inspecting body parts by eye or in mirrors, refraining from questioning others or seeking reassurance, wearing previously avoided clothes that remind the person of the deformity or accentuate what they imagine it is, not consulting physicians or surgeons, not running away from or avoiding situations where they imagine they are being scrutinized by others, etc.


A good example of a treatment situation was the case of a man who believed he had numerous spots, or marks on his face. Others could not see them. He did convince a reluctant dermatologist to try different therapies on him, including several laser treatments. This treatment never produced satisfactory resultsthe spots never seemed to go away. He finally sought therapy. His behavioral treatment involved listening to tapes telling him how ugly the marks made him, how because they would never go away, and that he would be deformed for life. Additionally, he was instructed to cease visiting the dermatologist, to stop spending hours stating at his face in the mirror and to not question friends or relatives about his appearance. He felt quite anxious and nervous at the start of treatment, but the above instructions, combined with antidepressant therapy, resulted in recovery over a three-month period.


Generally, by combining this type of treatment with an OCD drug approach suited to the individual, symptoms and anxiety can be greatly reduced, if not eliminated. Please note here that I am speaking from my own clinical experience; much more research needs to be carried out in the use of these treatments for BDD to judge their effectiveness. I can say though, that these are the only two approaches I have ever seen work for this disorder. When other OCD symptoms are present as well, they will also benefit from medication and behavioral therapy, sometimes responding even more so than the BDD symptoms.
Can everyone with BDD benefit from such treatment? Honestly, the answer is no. Some individuals with BDD have such an unshakable belief in their deformity that they either refuse to engage in the treatment at all, or else will do it, but only halfheartedly, as they believe that everyone else is wrong and they are right. What percentage of those with BDD falls into this category is not known. I would advise those with the disorder to give treatment a chance; sometimes those whose beliefs seem very strong can still be successful by first starting with medication which can weaken and reduce the thoughts, and then make them more receptive to the idea of therapy. Family counseling for those close to BDD sufferers can also be of great help. This is a very puzzling problem for those who are a part of a sufferer's everyday life and who are uninformed as to what is happening. With help, family members can learn to be supportive of efforts to seek treatment, and to not pressure, punish, or ridicule as a way of dealing with the sufferer.


The number of therapists who can treat BDD probably remains small at this time, but there are those familiar with OCD who should be able to adapt their methods. Just be sure they are qualified and if you don't immediately find one, keep looking. Persistence is the key to beating OCD and OC related problems.


Additional Readings: Phillips, Katharine A.: Body Dysmorphic Disorder: The Distress of Imagined Ugliness. Am J. Psychiatry 148:9, September 1991.

Hollander, Eric, M.D. et al: Treatment of Body Dysmorphic Disorder with Serotonin Reuptake Blockers, Am J. Psychiatry, 146:6 June 1989.

Schrof, Joannie M.: Reflections of Torment,US News & World Report, November 25,1991.

When It's More Than Meds & "Let Down"

Bron : http://www.yestheyrefake.net/body_dysmorphic_disorder.htm

This is in no way an attack on anyone or a matter of disbelief of the viable reason for depression you may be going through. This is a proven concern and the rate of incidence is alarming. Depression can be from medications, anesthesia, mental trauma, pre-existing psychological disorders, unrealistic expectations or post-operative pain, complications, lack of communication, surgeon error or normal after effects that the patient was not aware he or she would experience.

I actually did not believe in nor did I agree with disorders such as the newly diagnosed and much thrown around Body Dysmorphic Disorder (BDD) until I came across several patients who in fact DID have it and kept getting surgery to attain a happiness that surgery would never bring them. Obviously the disorder itself has always been around, and seemingly either the diagnoses have increased or the cases din general have increased. However, so has the population so one probably cannot make a truly informed opinion without examination of persons with BDD in the past or their case notes. Reagrdless, it is a real problem and it must be treated with delicacy. No one wants to be told they have BDD. But having friends with BDD, I can say that it was a wonderful day once they realized they did indeed have an issue with their body image.

Mark B. Constantian, M.D., F.A.C.S. recently reported in article aimed at diagnosing BDD in secondary rhinoplasty patients:

"Prior to surgery, an estimated 75% had true functional pathology, undiagnosed, yet real, surgical problems, or "unremarkable" personalities (i.e. not perfectionistic, depressed, or demanding)

Only one-quarter had, in the surgeon's judgment, minimal defects, an unreasonable attitude toward the defect, or depression, though the indications for surgery remained valid.

On the other hand, the results illustrated how difficult it is to identify the rare patient with BDD, a mental disorder characterized by a slight or imagined body defect that triggers severe emotional distress; the nose is the source of distress in nearly half of all cases." (Constantian, MB: Identify BDD patients prior to rhinoplasty; Cosmetic Surgery Times, June 2001)

If the above is true 1 out of every 4 secondary or tertiary rhinoplasty patients who read this page have BDD. I tend to think that is a little too high of a calculation but it is food for thought and should be considered by all of us. I know MANY people with rhinoplasty and surely not every fourth person had an image disorder.

The below information is in no way an accusation but is provided solely for the purpose of research and awareness. This is not a hypocritical statement either because although there is a fine line between what is healthy and what is not over obsessing and having your nose consume you is very unhealthy indeed. I honestly could live without a revision but I have to undergo a turbinate cauterization anyway - while "under" I might as well fix the dent. The turbinate cauterization is actually going to hurt more than the cosmetic part of the surgery. I know, I know, you're thinking, "whatever you have to tell yourself, girl!"

Anyway, I have provided this in case someone you may know may need help or has a self image disorder - know the signs. This is a very serious disorder and leads to years of unnecessary body modification and severe depression - sometimes even suicide! You could save your friend years of anguish and maybe even their life.

As a matter of fact rhinoplasty is the top procedure among those who experience post-surgical depression, along with liposuction, face lift and facial implants. Unfortunately rhinoplasty is also the top procedure of persons with self image disorders...

Body Dysmorphic Disorder (BDD)
Another important aspect is to realize that Body Dysmorphic Disorder MAY be a problem. Please do not get defensive until you truly understand the boundaries and symptoms of this disorder.

The standard or typical description of BDD by the American Psychiatric Association:

Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.
The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (also known as DSM-IV). Copyright © 1994 American Psychiatric Association.


Symptoms of Body Dysmorphic Disorder

Frequently comparing your appearance with that of others; scrutinizing the appearance of others

Often checking your appearance in mirrors and other reflecting surfaces.

Camouflaging the perceived defect with clothing, makeup, a hat, your hand, your posture, or in some other way that diverts the attention of the "defect"

Seeking cosmetic surgery, dermatologic treatment, or other medical treatment for appearance concerns when doctors or other people have said such treatment isn't necessary

Questioning and "fishing for compliments"; seeking reassurance about the flaw or attempting to convince others of its apparentness

Anger or resentment towards those who do not see your perceived flaw

Excessive grooming (i.e. combing hair, shaving, cutting hair, dyeing hair, applying makeup and/or concealers)

Avoiding mirrors and reflective surfaces

Frequently touching the defect

Picking and touching your skin

Repeatedly measuring the disliked body part

Excessively reading or searching the internet about the defective body part

Excessive exercise or dieting

Avoiding social situations in which the perceived defect might be exposed

Frequent absenteeism from school or your place of employment because you feel "ugly"

Failure to uphold a job for fear of someone seeing your perceived "defect"

Failure to hold a job because you are depressed about your appearance

Avoiding leaving the house for fear of someone seeing your perceived "defect"

Feeling very anxious and self-conscious around other people because of the perceived defect

But it really goes further than this. Speaking as a patient and a person who has come across patients who have been diagnosed with such and who have had extensive surgery - these patients don't want to hear it, they don't want to admit it and they think most surgeons, psychiatrists or even friends are against them. I am not saying this to sound like some sort of know-it-all or to only "prove" that am not on "your side" if this pertains to you. I am in fact going out on a limb here because this IS a very sensitive, yet important factor, of revision rhinoplasty. I am only going to give you my honest opinions and observations, as well as proven statistics and articles written by respectable doctors.

When I first began researching long ago with plastic surgery, in general, I noticed that the diagnosis of BDD was very common and, in my opinion, too often given with a prescription for medications as if it were candy. I admit it, at first I was very disappointed with the psychiatric society, in general, passing out the BDD diagnosis in the same trend as ADD (Attention Deficit Disorder) until I realized that there was an increasing trend in plastic surgery with persons who were diagnosed with BDD or typical clinical depressions.

It must be said that although it is difficult to diagnose BDD if you are not trained to recognize the symptoms, these individuals who are afflicted with such do slip through the cracks and onto the operating table and wind up becoming even more depressed and withdrawn from society after their secondary, tertiary, and so on, revision surgeries. The plastic surgeon, although not having gone through extensive training in psychiatry, becomes experienced in turning patients away who fit certain criteria or give a surgeon a "bad feeling" or "red flag".

I am not against those who have certain issues about their body having surgery but it MUST be realized that surgery will not help those who are truly afflicted with these disorders. It will not make you a different person, or make you more popular, get you more dates or make you a super model. Many BDD patients are not in the mental state to recognize what is considered attractive by most or even by themselves. They really don't know what they want but they know that they don't want to look like they presently do. But if given the chance to have the exact result desired -- the dysmorphia is still present and presents a problem in the healing stages. The patient then becomes obsessed even further and convinced that he or she is ugly in general -- not to mention, unsatisfied with a result that is considered by most to be exemplary.

You may argue that it is the patient that must be satisfied with his or her result, and you are very right - they should be and that is what is truly important. But if the patient does not KNOW what is attractive to them and will always be unsatisfied with the outcome it is very unhealthy. If they are not capable of accepting a great outcome and see fault where there is none. What then?

"BDD and secondary, tertiary, etc. rhinoplasty is most often seen in males" according to Dr. Mark B. Constantian. It has also been noted by The American Academy Of Cosmetic Surgery that 2% of cosmetic surgery patients have it. That may seem low to you but of this 2% it is most often observed in rhinoplasty and liposuction/lipoplasty patients. When you do the math - that's a lot of nose jobs.

This is in no way an attack on your person but a means with which to ask yourself if you are truly in possession of an unattractive nose or an outstanding one. Please seek help or at least research this disorder even if you do NOT think you have it. It is good to read up on and you just may realize that you have more in common with some BDD patients than you'd think. At the very least you could understand the pains that others who DO have BDD go through and perhaps help someone with your knowledge. I do ask that you do NOT research BDD for the sole reason of fooling or tricking a plastic surgeon into thinking that you are "normal" and I use that term very loosely. Of course we all have our different opinions and preferences for what is attractive however repeated dissatisfaction and obsessing is both unhealthy and dangerous, when we repeatedly hear that everything is fine and that we are imagining it - it pays to listen sometimes. Do yourself or someone you know a favor and know the warning signs before it's too late.

Suggested Reading on Body Dysmorphic Disorder

Body Dysmorphic Disorder Tutorial

Books The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder by Katharine Phillips, M.D. - click the book to buy or read excerpts
review coming soon!

The Adonis Complex: The Secret Crisis of Male Body Obsession by Harrison G. Pope Jr., MD; Katharine A. Phillips, MD; Roberto Olivardia, PhD - click the book to buy or read excerpts
I read this book to help to better understand body dysmorphic disorder. Although I am not a licensed psychologist I do have experience in interviewing persons with image disorders, or those who teeter at the threshold while battling daily with low self esteem poor body image. There is an amazing number of people who are unhappy with their bodies - unfortunately some of these may never be comfortable with their body image.

This book covers the male aspect of body dysmorphic disorder ranging from obsessive weightlifting to extreme dieting or supplementation. Males are no different from females in their desire to look their best. Due to the majority of porn targeted at men - for years it was thought image disorders were a thing only women were plagued by. Wanting to look like Barbie or a centerfold seemed common for women. Yet for men, seemed to detract from their masculinity. This book helps show the side of the coin where it isn't how you FEEL about your masculinity that questions it somehow - but how you LOOK. Many men feel that if their biceps are not hard as steel or their middles cut like a diamond, they somehow do not measure up. Welcome to the world of what psychologists call the "Adonis Complex" hence the book's name.

I have come across so many men who feel they must look their best no matter what and CONSTANTLY worry what they eat or how they look and still walk around in sweats without showing an inch of abdominal flesh. Many aren't hitting the gym for strength or jogging for great distances in the heat for cardiovascular health - they are striving to become an ideal which is unattainable.

The Adonis Complex covers symptoms to look out for and offers understanding to the many men who are determined to have the body of a Roman God and will do almost anything to get there. A definite read if you a male and in need of answers or have concerns which need to be quelled. Male body dysmorphia is sometimes compared to anorexia nervosa and can be equally harmful. Even if you do not feel that you have an image disorder, if you are active in the gym and are concerned with "ideal" body fat percentages perhaps you could look upon this book to help understand those you may come into contact with at your gym. While there is nothing wrong with wanting to look our best or feeling better when we do look tanned and tone - putting ourselves into harms way or letting this desire take over our social life is unhealthy and should be addressed.

Appearance Obsession: Learning to Love the Way You Look by Joni E. Johnston - click the book to buy or read excerpts
I first must say that I believe beauty is relative. This book is written by a clinical psychologist who was bombarded by family members nudging her towards perfection throughout childhood. It saddens me to know that I know SO many women who feel the exact same way and I wonder truly how much the media does have to do with this all. Is it not the consumers who buy the magazines which portray the waif-thin models? After all aren't we supposed to be looking at the clothes and not the body?

We all know that there are two sides to every coin but we also know that society and eve our own family members may show intentional, or unintentional, favoritism to those whose appearances shine. And I don't mean from an oily T zone. I mean true beauty. Everyone would be lying if they say that they don't feel better when they look their best than when they have gained a little (or more) weight, have a break out or "have nothing to wear". We have all been affected by how we look to ourselves and how others believe we look.

Some may argue that this book is not for those who truly "need" to lose weight or have plastic surgery and that it is more for people who are attractive and are "too sick to see it". This is ludicrous - beauty is relative and that is just another ridiculous arm of society depicting what is more attractive than the other. This book is helpful for ALL people in ALL walks of life which way be uncomfortable with the way they look. It is about being unhappy or self conscious with the way you look, not how maybe you are a little over or underweight than the next person - it is about feeling the need to look good and realizing what can be changed healthily.

This book is a first person account of the authors pain growing up and realizing just exactly how events can trigger neuroses or lack of esteem, at a very young and impressionable age. It contains questionnaires and surveys to determine your level of self esteem and just how much you are affected by media coverage of the beautiful. Personally I am a little tired of hearing that it is JUST the media's fault. People know what is attractive to them - it isn't like we are THAT impressionable. Nature takes precedence - Read Nancy Etcoff's "Survival of the Prettiest" for a not so new look at what drives us to become attracted to those who are "beautiful".

I still recommend this book, however - I like the way it is written and enjoy reading and comparing the author's experiences. It contains helpful advice and offers support ion an seemingly individual level Just don't allow yourself to use the media as a crutch for any lack of esteem you may have. I think there are far more issues at stake to cause image problems - such as personal experiences, relationships or lack thereof, chemical imbalances and random incidents can all trigger low self esteem.

For more information on societal ideals and appearance, see our "Ideal Beauty?" section.

Online Support Groups
We are not affiliated with the groups below but have provided the information for your convenience.

Body Dysmorphic Disorder eGroup (private): Post message: BodyDysmorphic@yahoogroups.com
Subscribe: BodyDysmorphic-subscribe@yahoogroups.com
Unsubscribe: BodyDysmorphic-unsubscribe@yahoogroups.com
List owner: BodyDysmorphic-owner@yahoogroups.com

Excerpts from this page published in Teen Decisions: Body Image (The Gale Group; Thomson-Gale, Greenhaven Press 2002)
Jacobson WE, et al. Psychiatric evaluation of male patients seeking cosmetic surgery. Plast Reconstr Surg, 26:356, 1990
Phillips KA, et al. body dysmorphic disorder. Am J Psychiatry 148:1, 1991.
Pertschuk M. Psychosocial considerations in plastic surgery. Clin Plast Surg 18:11, 1991
Tardy, ME. Rhinoplasty: The Art and Science, Volume II, Saunders press, 1997
Goin M, Rees T, Plast Surgery, 27:3, 1991
Constantian, MB: Identify BDD patients prior to rhinoplasty; Cosmetic Surgery Times, pp21-22, June 2001

Body Dysmorphic Disorder

Bron : http://www.ocdhope.com/bdd.htm

(The following is an abridged excerpt from "The OCD Workbook - Your Guide to Breaking Free from OCD" by Bruce M. Hyman, Ph.D. and Cherry Pedrick, RN. To learn more about "The OCD Workbook" and order a copy, click here)

Body dysmorphic disorder (BDD) is a preoccupation with a minor bodily defect or imagined defect which is believed to be conspicuous to others. It causes significant distress or impairment in functioning. The name is derived from the Greek word, dismorfia – dis meaning abnormal or apart, and morpho meaning shape. Before 1987, BDD was referred to as dysmorphobia, so named by psychopathologist Enrique Morselli in 1891.

Most people with BDD are not "ugly" at all. Their physical appearance is likely to go unnoticed. They are usually shy, with poor eye contact and low self-esteem. They often go to extremes to camouflage their imagined ugliness, wearing sunglasses, hats, or bulky clothing.

Several studies have found that almost 90% of BDD obsessions are face related, followed by hair, skin, and eyes (Yaryura-Tobias and Neziroglu, 1997b). But any body part can be the focus of concentration. Often, people with facial and skin dysmorphia pick and dig at their skin. Some have concerns involving body symmetry. Others have muscle dysmorphia, a type of BDD in which patients worry that their bodies are small and puny. Usually just the opposite is true; typically they are typically large and muscular. BDD by proxy is a form in which a person obsesses about supposed flaws in another person’s appearance.

People with BDD frequently lack insight or awareness of their problem. They frequently seek cosmetic surgery or dermatologic treatment for their perceived physical defects and are highly unlikely to seek help from a mental health professional until depression becomes a significant factor in their distress. There is often a high degree of overvalued ideation or even delusional thinking. In addition to the obsessional nature of BDD, one study found that 90 percent of patients with the disorder performed one or more repetitive and often time-consuming behaviors (Phillips, 1998). These are behaviors intended to examine, improve, or hide imagined defects, such as mirror checking, grooming, shaving, washing, skin picking, weight lifting, and comparing self with others. People with BDD may seek reassurance from others or try to convince others of their defect.

Body dysmorphic disorder usually begins in adolescence, though it can start in childhood. There seems to be a slightly higher prevalence in males – one large study reported 51 percent were men. Obsessive-compulsive disorder is common in people with BDD, occurring in over 30% of patients. In one study, depression had a 60 percent rate of occurrence (Phillips, 1998).

Though most patients with BDD are reluctant to take medication, serotonin reuptake inhibitors (SRIs) are the medications of choice to treat BDD. Successful medication therapy can result in a decrease in time preoccupied with the imagined defect, less time spent on associated compulsive behavior, less distress, and reduced depressive symptoms. Often, patients gain improved insight into their BDD problem. As with OCD, relapse is usually a problem when medication is stopped.

Preliminary studies suggest that cognitive-behavior therapy can be helpful for people with BDD. Exposure and response prevention combined with cognitive techniques were effective in 77% of BDD patients in one study (Phillips, 1998). Often the challenge is getting someone to accept psychiatric treatment rather than dermatological, surgical, or other medical treatments. More research into BDD is needed. But there is hope. There are good treatments available for BDD.

Body Dysmorphic Disorder

Bron : http://www.groovynetdiva.com/bdd.html

Dissatisfaction with how you look is not unusual in this day and age. With all the power advertising and media publications pushing appearance all us from all sides it is quite normal for many of us to think we do not quite cut the mold of perfection. Appearance has always played a big part in life for most people but never in history have we witnessed so many feeling the need for artificial enhancement and alteration of their bodies and faces. The past decade has seen a major trend towards plastic surgery for women as well as men. Instead of accepting ourselves as we are science has given us an alternative.

The dissatisfaction of personal appearance is prevalent in our society. This is not uncommon at all but when someone becomes intensely preoccupied with what they believe to be a defect in their appearance, then they may well be suffering from a mental health condition called Body Dysmorphic Disorder (BDD).

BDD is not often recognized since everyone gets concerned about physical imperfections. A person suffering from BDD may seem quite normal to the outside world but they often feel intensely tormented and tortured by what they feel makes them ugly to themselves and to those around them. While there may be a real concern with some deformations or ailments such as extreme acne or deformities, a person with BDD will be preoccupied intensely and excessively with the problem.

The BBD condition often goes undiagnosed and the suffered may seek repeated cosmetic surgery to remedy the imagined defects. People with the disorder usually complain about flaws of the face. They become obsessed with the size and shape of their noses, eyes, ear, mouths, chins and jaws. They may agonize over the real or imagined appearance of wrinkles, the color or shading of their skin or even thinning hair. The focus may at times shift to their bodies also. Preoccupation with their tummy, hips, thighs and genitals is not uncommon. Sufferers often find themselves standing in front of mirrors checking their appearance. Often they stay away from others due to what they think others see in them. They shun the company of people so that they have no one to compare their flaws to. Often they become paranoid others are mocking them or talking about their imperfections behind their backs. BBD leads to much more sever mental problems if left untreated.

Body Dysmorphic Disorder often begins in adolescence when young people are having to deal with the natural changes occurring in their bodies. Changes in shape and size often trigger BDD. Issues of sexuality and gender identity also arise at this time. Young people are more prone to take what media and society is pushing at them to heart. At this age BDD occurs at the same rate in females as it does in males. The anxiety that teens feel about the many changes occurring is usual handled in time but for some it does not become manageable and leads to more severe problems.

At some point the differences in the genders becomes apparent with BDD. The current tendency to idealize thinness, as illustrated by imaged of slender models by the media, has a particular impact on girls because of the development of breasts and hips seem to be in conflict with the cultural ideal. Due in the main to modern nutrition the average woman has become larger and this has brought about conflicts to the ideal they are seeing as the way they should be. The natural change which boys undergo, as they become taller and more muscular is more in tune with the cultural ideal for men.

BBD can become so overwhelming to the sufferer that it often is linked to depressive disorders and social phobia. Medically it is common for doctors to have patients complaining of depression tested for BDD. Much like depression BDD sufferers often find it extremely difficult and embarrassing to disclose their concerns. It is difficult to know just how prevalent BDD is as there is such great cultural preoccupation with beauty and attractiveness. Tendency for many to be preoccupied with their bodies and shape is quite normal these days. All these factors mask and normalize what be seen in other cultures to be an excessive interest in one’s appearance. Confusion exists in modern times about how much time is normal for makeup application and how much plastic surgery is normal and what is too much. With so much focus on appearance becoming the norm BDD sufferers often think they are just like everyone else leading to less treatment and longer-term mental problems.

How much distress or impairment is necessary before a condition becomes clinically significant is the question we need to focus on. If someone feels they are suffering a great deal of psychological distress because of their obsession and preoccupations, then they are. If a close family member or friend sees someone suffering a great deal of distress, embarrassment and the efforts of change to their appearance, withdrawal from society then they are seeing a problem. The sufferer may deny that any problem exists but it needs attention since it is not a condition that will go away untreated. There is no virtue in continuing to suffer or keep the condition secret. BDD is treated through medication and counseling and is not a condition that we have to live with.

Insight and Body Dysmorphic Disorder
Michael A. Tompkins, Ph.D.

Bron : http://www.sfbacct.com/articles/art-insight_body.html

Body dysmorphic disorder (BDD) is characterized by excessive preoccupation with an imagined defect in appearance which results in significant distress and impairment in social, occupational, and other important areas of functioning. Take the middle-aged attorney with BDD who was convinced that his lips were too thin. This troubled him on dates, at professional and social occasions and, most distressing of all, in the courtroom. He was convinced that his thin lips meant to jurors that he was unscrupulous, mean-spirited and untrustworthy. Because of his BDD, the attorney had stopped litigating and his income had dropped significantly. He was afraid to go out with friends or on dates and spent most evenings at home, alone and depressed.

50-60% of individuals with BDD exhibit poor or no insight. By insight I mean the ability of a person to recognize that his view of his appearance is inaccurate. For example, an older woman with BDD was distressed about the size of her nose. I concluded she had poor insight when, in response to my question about how it was that yesterday she had said her nose was fine but today she said it was too large. She answered, "My nose changed since yesterday."

We know that the degree of insight an individual with BDD has is an important predictor of treatment outcome (poor insight often means poor outcome). The poor outcome may be largely due to the individual’s inability to say to himself at least at times, "Well, maybe my view of myself is distorted." Without this ability to step back a bit, the individual is not capable of making good use of cognitive-behavioral interventions for his BDD.

Here are several cognitive-behavioral strategies that I’ve found helpful in improving these patient's insight..

Sel-monitoring. I ask the individual to monitor how his BDD symptoms vary over time. Every hour he rates (0–10) how strongly he believes, for example, that his nose is too large. He also notes what was happening at the time and how he was feeling. We then plot on graph paper the strength of the person’s belief, where 10 is "my nose is too large" and 0 is "my nose is fine." Sometimes seeing his belief fluctuate by the hour helps the client recognize that he can’t always trust his view of himself.

Cognitive restruturing. Individuals with BDD have distorted beliefs about their appearance, such as "I have to look perfect,' or, "If I don’t look good, I’ll be rejected and alone." Teaching individuals to identify and restructure these distorted beliefs can sometimes help the person gain enough insight to try other CB strategies.

Cognitive distancing. Individuals with BDD have difficulty accepting that they have BDD because that would mean their appearance is okay. One young man who told me session after session that he did not have BDD. What he had was a left ear that was lower than the right ear. He insisted that only plastic surgery would correct the problem. I commiserated with him and said that plastic surgery was certainly a logical solution to the problem of a true flaw in his appearance but that it was not a solution to BDD. The problem as I saw it was that every time his BDD flared up he bought into the belief that his appearance was flawed. I then taught him a cognitive distancing strategy described by Jeffrey Schwartz in his book titled Brain Lock. Schwartz describes the 4 Rs. I’ll cover the first three here. The first R is "relabel." The client was taught to relabel any concern, thought, or belief about his appearance as a feature of the BDD, not proof of a physical flaw. He was then to use the second R (reattribute) to attribute every aspect of his experience (his thoughts, feelings, urges, and behaviors) to the BDD. He was then instructed to refocus (3rd R) or distract himself from the BDD thoughts.

An "as if" attitude. At times I have asked a client to act "as if" he looks okay even if he doesn’t believe it. An "as if" attitude is particularly helpful when trying to get a client to try an exposure exercise that, because of his poor insight, he believes is useless. I’ve asked clients to use the "as if" attitude to stay at a party when they have a strong urge to leave, to go to social situations when they are inclined to remain home alone, or to stop looking in a mirror when they feel that they must continue. One of my clients used this strategy to go to a party that he wanted to avoid by acting "as if" he was okay and "as if" going to the party would help his BDD and his depression. Once at the party, he was able to use his CB strategies to manage his BDD and that as the evening progressed, he was much less worried about his appearance.

A Randomized Placebo-Controlled Trial of Fluoxetine in Body Dysmorphic Disorder

Bron : http://archpsyc.ama-assn.org/issues/v59n4/abs/yoa10089.html

Katharine A. Phillips, MD; Ralph S. Albertini, MD; Steven A. Rasmussen, MD

Background Research on the pharmacotherapy of body dysmorphic disorder (BDD), a common and often disabling disorder, is limited. Available data suggest that this disorder may respond to serotonin reuptake inhibitors. However, no placebo-controlled treatment studies of BDD have been published.

Methods Seventy-four patients with DSM-IV BDD or its delusional variant were enrolled and 67 were randomized into a placebo-controlled parallel-group study to evaluate the efficacy and safety of fluoxetine hydrochloride. After 1 week of single-blind placebo treatment, patients were randomized to receive 12 weeks of double-blind treatment with fluoxetine or placebo. Outcome measures included the Yale-Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS) (the primary outcome measure), the Clinical Global Impressions Scale, the Brown Assessment of Beliefs Scale, and other measures.

Results Results of the BDD-YBOCS indicated that fluoxetine was significantly more effective than placebo for BDD beginning at week 8 and continuing at weeks 10 and 12 (F1,64 = 16.5; P<.001). The response rate was 18 (53%) of 34 to fluoxetine and 6 (18%) of 33 to the placebo (21 = 8.8; P=.003). The BDD symptoms of delusional patients were as likely as those of nondelusional patients to respond to fluoxetine, and no delusional patients responded to the placebo. In the sample as a whole, treatment response was independent of the duration and severity of BDD and the presence of major depression, obsessive-compulsive disorder, or a personality disorder. Fluoxetine was generally well tolerated.

Conclusion Fluoxetine is safe and more effective than placebo in delusional and nondelusional patients with BDD.

Arch Gen Psychiatry. 2002;59:381-388

Body Dysmorphic Disorder: a Common But Underdiagnosed Clinical Entity
by Fugen Neziroglu, Ph.D.
Psychiatric Times January 1998 Vol. XV Issue 1

Bron : http://www.psychiatrictimes.com/p980111.html

Most clinicians had never heard of body dysmorphic disorder (BDD) until the early 1990s, and it was not in the Diagnostic and Statistical Manual of Mental Disorders until 1987. This does not mean it did not exist. In fact it was written about as early as 1891 when Morselli (1891) described dysmorphophobia (a name given to it until DSM-III-R when it was changed to BDD) as a subjective feeling of ugliness despite a normal appearance, and our conceptualization of the disorder does not differ significantly.
BDD is currently classified under somatoform disorders in DSM-IV. However, it remains debatable whether BDD represents a symptom, a syndrome or an obsessive-compulsive spectrum disorder. The researchers who believe it is an obsessive-compulsive spectrum disorder do so because BDD patients have obsessions and compulsions, and respond to similar pharmacological agents, as well as behavior and cognitive therapy, as do OCD patients (Hollander and Phillips, 1993; Neziroglu and Yaryura-Tobias, 1993a, b; Phillips et al., 1993). Typically, the obsessions revolve around the face (e.g., wrinkles, scars, vascular markings, acne, redness, paleness, excessive facial hair, size, shape or asymmetry of any facial feature), genitals, breasts, buttocks, abdomen, hands, feet, shoulders and back.

Patients obsessed with facial deformities may resort to face picking and skin digging, sometimes to the point of actually scarring the face. For example, patients may become obsessed with a pimple, and in their attempt to get it out they dig their nails into their skin. If that does not work they may try tweezers and sometimes even carving the pimple out with a knife. Self-mutilation may also take the form of face picking, pulling on the nose with pliers to "even it out" and sanding the teeth until the enamel is worn off. Other behavioral responses to BDD obsessions include compulsive mirror checking, episodic avoidance of mirrors, excessive grooming (e.g., ritualized makeup application, hair styling, skin treatments, hair removal), camouflaging (e.g., wearing hats to cover hairline, using a mustache to cover the upper lip, wearing baggy clothes or sunglasses), reassurance seeking, surgery and unnecessary usage of dermatological products.

BDD often interferes with patients' functioning. Those with BDD tend to avoid usual activities, are late, have difficulty working or going to school, experience difficulty in sexual relations, may become homebound, and may require hospitalization. Most patients are in the moderate to severe range, and often hold on so strongly to the belief that they are unattractive that this belief may be classified as an overvalued idea. At times, it is close to delusional. The strength of the distorted belief can be assessed using the Overvalued Ideas Scale (Neziroglu et al., 1996), which was developed by my colleagues and me.

For patients suffering from BDD, insight in the realm of their appearance may be minimal, although judgment tends to remain intact in other areas. This population often seeks treatment from dermatologists and plastic surgeons first. They often end up in the office of mental health professionals, usually at the request of their families, only after attempts at physical "corrections" have failed.

It is estimated that approximately 1.5% of the population has BDD. However, due to the secretive nature of BDD patients, it is possible that the prevalence rates are much higher. These patients are usually very shy, avoid discussion about their defect with others and may evidence schizotypal tendencies. Body dysmorphic disorder is not included in the Structured Clinical Interview for DSM and often is underdiagnosed. Clinicians lack a clear understanding of the disorder and therefore don't ask the proper questions (e.g., patients are unlikely to tell you about the defect, but may talk about depression, anxiety or other obsessions). In addition, patients tend to seek treatment from other medical specialties.

Male-female ratio is equal and the onset of the disorder appears to be between the ages 14 and 20. BDD is differentiated from the normal preoccupation with attractiveness seen in adolescence by its severity, chronicity and interference in the individual's life.

Although BDD is a difficult disorder to treat because of the strong conviction most patients have about their unattractiveness, available research supports certain behavioral, cognitive and pharmacological approaches. (For an in-depth review of the available literature see Yaryura-Tobias and Neziroglu (1997a,b), and Neziroglu and Yaryura-Tobias (1997).

Several researchers have found that a form of behavior therapy known as exposure-and-response prevention (ERP) is effective (Marks and Mishan, 1988; Neziroglu & Yaryura-Tobias, 1993a,b; Rosen et al.,1995). Recently, cognitive therapy was also noted to be extremely helpful (Geremia and Neziroglu, 1997). ERP refers to exposing the "defect" of the patients while at the same time preventing them from engaging in their compulsions.

An example would be exposing the "defective nose" in public with gradations of closeness to others. A patient who obsesses about his large nose would be asked to speak to others in public as they get closer and closer to others while speaking. If he is more anxious about being seen in bright light versus a dim one, the therapist would take him to a store, restaurant or any setting with fluorescent lighting. If he is more anxious about being seen close-up by females than males, female salespeople would be chosen for him to speak to, and the like. At the same time, the patient would be asked to refrain from checking the mirror or covering his nose with his hand. Towels may be used to cover up mirrors in the house to prevent checking between sessions. The cognitive therapy aspect involves challenging specific faulty or erroneous thoughts these patients have.

Some common cognitive distortions in BDD are the following: I must be perfect, I must be noticed, the only way to feel better is to look better, if I am not the best looking in a social gathering I cannot have a good time, if my body part of concern is not beautiful, then it must be ugly.

In cognitive therapy, patients are taught how to challenge and derive alternative explanations for these kinds of thoughts. However, it has been noted that unlike OCD patients, BDD patients often respond with depression rather than anxiety when they are undergoing behavior and cognitive therapy. Cognitive therapy may be more effective when it's done at the onset of treatment and then followed by behavior therapy.

Most often these patients also need pharmacological interventions. The medications most likely to be effective are clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine (Luvox), and pimozide (Orap) (Jenike, 1984; Fernando, 1988; Hollander et al., 1989; Stout (1990); Phillips, 1991; Phillips et al.; Neziroglu and Yaryura-Tobias, 1993a). To date, the treatment research on BDD is limited, but it is the opinion of the author that these patients do best with treatment that combines a psychopharmacological and cognitive/behavioral approach.

Note: This is Dr. Neziroglu's third article on obsessive-compulsive spectrum disorders. For the first two articles, refer to the March and June, 1997, issues of Psychiatric Times-Ed.)


Dr. Neziroglu is a behavior therapist and clinical director of the Institute for Biobehavioral Therapy and Research in Great Neck, N.Y., and senior consultant of the Obsessive-Compulsive Disorder Inpatient Program at North Shore University Hospital.

Fernando N (1988), Monosymptomatic hypochondriasis treated with a tricyclic antidepressant. Br J Psychiatry 152:851-852.

Geremia G, Neziroglu FA (1997), Efficacy of cognitive therapy in the treatment of body dysmorphic disorder. Submitted for publication.

Hollander E, Liebowitz MR, Winchel R, et al (1989), Treatment of body dysmorphic disorder with serotonin reuptake blockers. Am J Psychiatry 146(6):768-770.

Hollander E, Phillips KA (1993), Body image and experience disorders. In: Hollander E, ed. Obsessive-Compulsive-Related Disorders. Washington, DC: American Psychiatric Press.

Jenike MA (1984), A case report of successful treatment of dysmorphophobia with tranylcypromine. Am J Psychiatry 141(11):1463-1464.

Marks I, Mishan J (1988), Dysmophophobic avoidance with disturbed bodily perception. A pilot study of exposure therapy. Br J Psychiatry 152:674-678.

Morselli E (1891), Sulla dismorfofobia e sulla tafefobia. Bolletinno della R accademia di Genova 6:110-119.

Neziroglu FA, Yaryura-Tobias JA (1993a), Body dysmorphic disorder: phenomenology and case descriptions. Behavioural Psychotherapy 21:27-36.

Neziroglu FA, Yaryura-Tobias JA (1993b), Exposure, response prevention, and cognitive therapy in the treatment of body dysmorphic disorder. Behavior Therapy 24:431-438.

Neziroglu FA, McKay D, Yaryura-tobias J, et al. (1996), Overvalued Ideas Scale: Reliability and Validity. Submitted for publication 1996.

Neziroglu F, Yaryura-Tobias JA (1997), A review of cognitive-behavioral and pharmacological treatment of body dysmorphic disorder. Behav Modif 21(3):324-340.

Phillips KA (1991), Body dysmorphic disorder: the distress of imagined ugliness. Am J Psychiatry 148(9):1138-1149. See comments.

Phillips KA, McElroy SL, Keck PE, et al. (1993), Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 150(2):302-308. See comments.

Rosen JC, Reiter J, Orosan P (1995), Assessment of body image in eating disorders with the body dysmorphic disorder examination. Behav Res Ther 33(1):77-84.

Stout RJ (1990), Fluoxetine for the treatment of compulsive face picking. Am J Psychiatry 147(3):370. Letter.

Yaryura-Tobias JA, Neziroglu FA (1997a), Biobehavioral Treatment of Obsessive-Compulsive Spectrum Disorders. New York: W.W. Norton.

Yaryura-Tobias JA, Neziroglu FA (1997b), Obsessive-Compulsive Disorder Spectrum: Pathogenesis, Diagnosis and Treatment. Washington: American Psychiatric Press.

'You're so vain': how going to art school can change your body image

Bron : http://www.rcpsych.ac.uk/press/preleases/pr/pr_340.htm

Annual Meeting: Psychiatry Today
Monday 24th to Thursday 27th June 2002
Cardiff International Arena, Cardiff
Artists, designers and people who have been to art school are a staggering five times more likely to suffer body dysmorphic disorder (BDD), a mental illness characterised by a distorted body image and a preoccupation with slight or imagined defects in physical appearance than other mentally ill patients.
A team of researchers led by Dr David Veale at London's Royal Free College compared 100 patients with BDD with 100 depressed patients, 100 with obsessive compulsive disorder and 100 with post-traumatic stress disorder.

20% of the BDD patients had a job in art and design or had been to art school compared with just 4% of depressed patients, 3% of those with obsessive compulsive disorder and none of those with post-traumatic stress disorder.

The study is consistent with other research which suggests that patients with BDD have idealised values about the importance of appearance and a tendency to perfectionism.

"Onset of body dysmorphic disorder is usually gradual during adolescence and an education in art and design my be a contributory factor to its development in some patients,' he said. 'Alternatively patients with body dysmorphic disorder may have a selection bias for an interest in aesthetics," he said.

A second study by the same group found that BDD patients were more like people with depression, social phobia and bulimia in that they were more concerned with their failure to achieve their own aesthetic standards than to meet the perceived ideals of others. 'This suggests that BDD patients have an unrealistic ideal or demand as to how they should look.'

The authors recommend that more investigations into the links between an education or career in art and design and body dysmorphic disorder would be worthwhile.

Image problems also affect men

Bron : http://www.everybody.co.nz/research/men_image.htm


Almost one-half of US men are unhappy with their appearance, meaning men are now almost as unhappy as women with body image. Body dysmorphic disorder is a serious form of body image disturbance. Men and women are more or less equally affected by this condition in which they become preoccupied with minor defects. Some become housebound or attempt suicide. In men, the main concerns are skin (acne and scarring), hair thinning or size of nose or genitals. Hours of mirror checking, grooming and camouflaging are suggestive of body dysmorphic disorder. Muscle dysmorphia is another form of the condition, sometimes occurring in patients who are brawnier than average. A fixation with gym workouts and diet is common, as is abuse of anabolic steroids. Education about the disorder and psychiatric intervention should be tried first. Medication used for depression is also effective.

Study details

Almost one-half of US men (43%) are unhappy with their appearance, a figure that has increased by 300% in the past 25 years. Men are now almost as unhappy as women with body image. Body dysmorphic disorder is a more serious form of body image disturbance. Men and women are more or less equally affected by this condition in which they become preoccupied with minor defects, real or imagined, to the point that distress or impaired functioning occurs. About 10% of people attending dermatology and cosmetic surgery clinics suffer from this disorder. The problem with the condition is that a significant proportion requires hospitalisation, becomes housebound or attempts suicide. Acne and body dysmorphic disorder are primary causes of suicide in dermatology patients. In men, primary concerns are skin (acne and scarring), hair thinning or size of nose or genitals. The perceived problem may consume many hours of each day with repetitive time-consuming behaviours attempting to fix their perceived problem. Mirror checking, grooming, camouflaging and seeking reassurance are common signs. Muscle dysmorphia is another form of the condition, presenting with symptoms of insecurity about muscular development, paradoxically occurring in many patients who are brawnier than average. A fixation with gym workouts and diet is common, as is abuse of anabolic steroids. Social pressures have increased the incidence of this condition. Consequences of the problem include social isolation and poor job performance. A range of trials confirms the utility of selective serotonin reuptake inhibitor therapy. Typically, higher doses than used in depression are needed and trials of therapy may need to be longer. Cognitive behavioural therapy may also be appropriate. Dermatological and surgical interventions do not seem to work, and in some these procedures lead to severe depression or suicidal ideation. Education about the disorder and psychiatric interventions are preferable. Body dysmorphic disorder remains poorly recognised and diagnosed. Patients often attempt to conceal the condition. Both physicians and the general public need to become more aware of the condition since effective treatments are available.
Phillips KA, et al. Br Med J 2001 323:1015-6

An Epidemic of Ugliness

Bron : http://home.attbi.com/~anxietyshrink/BDD_web.htm

There is a disorder known as Body Dysmorphic Disorder (BDD), which is understood to be on a spectrum with or closely related to obsessive-compulsive disorder (OCD) and or depression. This problem has had different names and is not as well known as OCD but turns out to be quite common. New research suggests that BDD may occur in 1-2% of the general population and in approximately 8-12% percent of people seeking help from mental health professionals for problems like depression. Researchers have found it to be common but not identified in people seeking hospitalization for depression, people seeking treatment from dermatologists, plastic surgeons and among general medical patients.

What is BDD? It is a disorder which involves preoccupation with a defect in appearance. The defect however is either nonexistent or so minor as to be insignificant as far as others are concerned. The preoccupation and behavior generated to deal with the concern take up a significant amount of time and cause important interference with the persons functioning. The person with BDD may invest large amounts of time, money and effort into trying to correct or hide the defect or may try to avoid situations where the defect will be noticed. They may spend significant amounts of time checking on their defect or comparing their appearance with others. The concern with appearance is like an obsession and the behavior can be seen as compulsive. BDD is often called the disease of imagined ugliness because although the person who has it thinks the defect is significant others don’t see it that way. This lack of agreement on the existence or importance of the defect is described as lack of insight. Because most people with BDD have limited insight into their disorder they are more likely to go to a dermatologist or plastic surgeon than to a mental health professional for help.

The defect or concern can be focused on almost any part of the body but most common concerns involve the face. Many people with BDD have more than one defect that bothers them. Over time the concern may shift. People with BDD often have other problems like OCD and even more commonly depression. It is estimated that 80-90% of people with BDD have serious depression. Depression is often so severe that it leads to significant impairment by itself and most people with BDD have had serious suicidal thoughts connected with their appearance concern. Dr Katherine Phillips a leading BDD expert reports that approximately 25% of BDD patients she sees have attempted suicide because of their BDD/depression problem.

If BDD is both as common and as serious as these figures suggest why is it so unrecognized? There are two factors that seem to explain it. One is that most professionals don’t ask. In a study of 122 patients admitted to an inpatient psychiatric unit at a university teaching hospital 13.1% (16 patients) were found to have BDD. However none were given the diagnosis by the psychiatrist treating them. They were never asked about possible symptoms or concerns that would have identified the disorder. The second factor is that people with BDD feel so much shame they almost never volunteer information about the complaint. In the same study all 16 patients with BDD said they would not tell about their concerns because of shame unless they were directly asked.

What can be done to help someone with this problem? The treatments of BDD that have evolved are the same as those we know work for OCD. Medication, primarily the serotonin reuptake inhibitors, seems to be helpful for most people with BDD. Cognitive behavioral therapy including exposure and ritual prevention has been found to be an important tool for BDD. Although the research is still preliminary treatment plan combining these approaches is probably the best choice for most people with BDD especially if their disorder is severe or accompanied by significant depression. There is no data on self-help treatment of BDD but we know that people with OCD can make important progress working on their own and the same sort of approach would be expected to help BDD. There are only a few books on BDD The Broken Mirror by Phillips and The Adonis Complex by Pope, Phillips and Olivardia. Dr Claiborn of Manchester Counseling and co-author Cherry Pedrick have recently completed work on a self-help book for people with BDD called the BDD Workbook from New Harbinger.

Body dysmorphic disorder in men
Psychiatric treatments are usually effective

Bron : http://bmj.com/cgi/content/full/323/7320/1015

Body image isn't just a women's problem. Many studies reveal that a surprisingly high proportion of men are dissatisfied with, preoccupied with, and even impaired by concerns about their appearance.1 One American study, for example, found that the percentage of men dissatisfied with their overall appearance (43%) has nearly tripled in the past 25 years and that nearly as many men as women are unhappy with how they look.1

A more severe form of body image disturbancebody dysmorphic disorder or dysmorphophobiais an underrecognised yet relatively common and severe psychiatric disorder.2 Body dysmorphic disorder affects as many men as women 3 4 and consists of a preoccupation with an imagined or slight defect in appearance that causes clinically significant distress or impairment in functioning. Patients with body dysmorphic disorder often present to non-psychiatric physicians, with reported rates of 12% in dermatology settings and 7-15% in cosmetic surgery settings.5 Although the symptoms of body dysmorphic disorder might sound trivial, high proportions of patients require admission to hospital, become housebound, and attempt suicide.3 In a study of dermatology patients who committed suicide most had acne or body dysmorphic disorder.6

Men with body dysmorphic disorder are most commonly preoccupied with their skin (for example, with acne or scarring), hair (thinning), nose (size or shape), or genitals. 3 4 The preoccupations are difficult to resist or control and can consume many hours each day.3 Nearly all men with body dysmorphic disorder perform repetitive and time-consuming behaviours in an attempt to examine, fix, or hide the "defect." The most common are mirror checking, comparing themselves with others, camouflaging (for example, with a hat), reassurance seeking, and excessive grooming.3

A recently recognised form of body dysmorphic disorder that occurs almost exclusively in men is muscle dysmorphia, a preoccupation that one's body is too small, "puny," and inadequately muscular.1 In reality, many of these men are unusually muscular and large. Compulsive working out at the gym is common, as is painstaking attention to diet and dietary supplements. Of particular concern, muscle dysmorphia may lead to potentially dangerous abuse of anabolic steroids, and studies indicate that 6-7% of high school boys have used these drugs.1 While the cause of body dysmorphic disorder is unknown and probably multifactorial, involving genetic-neurobiological, evolutionary, and psychological factors, recent social pressures for boys and men to be large and muscular almost certainly contribute to the development of muscle dysmorphia.

Body dysmorphic disorder interferes with functioning 2 4-7 and may lead to social isolation, difficulty with job performance, and unemployment. In a study that used the SF-36 to measure health related quality of life, outpatients with body dysmorphic disorder scored notably worse in all mental health domains than the general US population and patients with depression, diabetes, or a recent myocardial infarction.7

Patients with body dysmorphic disorder can be challenging to treat.8 However, recent research findings are encouraging, with clinical series, open label studies, and controlled trials indicating that serotonin reuptake inhibitors are effective for most patients.9 Higher doses and longer trials than those usually used for depression are often needed.9 Clinical series and studies using untreated controls waiting for treatment suggest that cognitive behavioural therapy is also effective.10 This treatment helps patients develop more realistic views of their appearance, resist repetitive behaviours, and face avoided social situations. Other types of psychotherapy or counselling, in contrast, do not appear effective.2

Most men with body dysmorphic disorder, however, receive dermatological, surgical, or other non-psychiatric treatment.11 Although rigorous studies are lacking, the data suggest that these treatments are usually ineffective.11 Some patients are so disappointed with the outcome that they become severely depressed, suicidal, litigious, or even violent towards the treating physician. A recommended approach5 is to educate patients about the disorder and effective psychiatric treatment. It is probably best to avoid cosmetic procedures. Simply trying to talk patients out of their concern is usually futile.

Although body dysmorphic disorder has been described for over a century and reported around the world, it remains underrecognised and underdiagnosed.2 Men and boys are often reluctant to reveal their symptoms because of embarrassment and shame, and they typically do not recognise that their beliefs about their appearance are inaccurate and due to a psychiatric disorder. Physicians can diagnose body dysmorphic disorder in men with a few straightforward questions. 5 12 These determine whether the man is concerned about and preoccupied with minimal or non-existent flaws in his appearance and whether this concern causes significant distress (depression, anxiety) or interferes with social, occupational, or other aspects of functioning. The challenge is to enhance both physicians' and the public's awareness of body dysmorphic disorder so that effective treatments can be offered and unnecessary suffering and morbidity avoided.

Katharine A Phillips, director, Body Dysmorphic Program.

Butler Hospital and the Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, Rhode Island 02906, USA (Katharine_Phillips@Brown.edu

When Plastic Surgery Doesn't Make You Feel Prettier

By Alison Palkhivala
Reviewed By Dr. Jacqueline Brooks

Bron : http://webmd.lycos.com/content/article/33/1728_83543


July 11, 2001 -- Will looking prettier on the outside make you feel better on the inside? For some, cosmetic surgery is a godsend -- an opportunity to, for example, restore a breast removed because of cancer or to correct disfiguring scars caused by acne. But for a select few, sometimes called "plastic surgery junkies," plastic surgery, especially repeat operations, is a sign of a psychiatric illness. These people may suffer from body dysmorphic disorder or "imagined ugliness", and for them, cosmetic surgery does not make them look prettier or feel better. Now, new research may help identify those with this condition. People with body dysmorphic syndrome believe they, or parts of their bodies, are horribly ugly even though they generally look fine. Expert Rod J. Rohrich, MD, says those who are easiest to spot are preoccupied with a physical "defect" so tiny most people can't even see it. "This preoccupation causes them to be totally impaired socially and functionally," Rohrich tells WebMD. "They won't go out, they won't go to their job, and their preoccupation is not explained by something else, like another psychiatric disorder or a death in the family." Rohrich is a professor and chairman of the department of plastic surgery at the University of Texas Southwestern Medical Center in Dallas. He was not involved in this research but has written about body dysmorphic disorder. People with body dysmorphic disorder are not helped by plastic surgery because once one "defect" is repaired they become preoccupied with another. These people will benefit more from mental health care, in the form of medication or psychotherapy, than from cosmetic surgery. Unfortunately, people with body dysmorphic disorder are hard to pinpoint. They blend into the crowd of individuals who are seeking plastic surgery because of a healthier desire to want a prettier nose or larger breasts. After all, most people are dissatisfied with some aspect of the way they look. What makes it a psychiatric problem is simply a question of degree of concern. Steve Kisely, MD, and colleagues compared individuals seeking plastic surgery purely for the sake of looking nicer to another group seeking plastic surgery for medical reasons. All participants filled out questionnaires about their mental health as well as their concerns about appearance. People whose responses indicated mental health problems, like anxiety, depression, and negative feelings about how they looked, were more likely to seek plastic surgery just to look nicer than because there was really something wrong. Therefore, these questionnaires could help identify people with imagined ugliness before they undergo another unnecessary nip and tuck. Kisely, an associate professor of psychiatry at Fremantle Hospital and a consultant in Consultation-Liaison Psychiatry at the University of Western Australia, is presenting his findings this week at the annual meeting of the Royal College of Psychiatry in London. "Plastic/cosmetic surgery may not provide the answer if you are very concerned about your appearance, and especially if your family/friends don't seem to understand your level of distress," says Kisely. "Psychological help may also be needed. The analogy is with anorexia nervosa. If you carry on dieting even when your family says you are too thin, further weight loss is not the answer. You may need other interventions."

Case Study: Body Dysmorphic Disorder and Major Depression

Bron : http://www.beckinstitute.org/october99/Case.html

by Terri Lustick, Ph.D., Clinical Associate

Body Dysmorphic Disorder is described in the DSM-IV as a "preoccupation with an imagined defect in appearance which causes clinically significant impairment in social, occupational or other important areas of functioning." Because of the feelings of shame which BDD patients tend to feel, this illness may often be underreported and underdiagnosed.
BDD tends to have its onset during adolescent years. The focus on the perceived "defect" appears obsessional and time-consuming. While concern might focus on any body part, the skin, hair and nose are most common sites of the preoccupation. Phillips et al (1993) report that 73% of those diagnosed with this disorder manifested associated ideas or delusions of reference, 97% avoided usual social and occupational activities, 30% were housebound and 17% made suicide attempts. Major Depressive Disorder is the most likely comorbid disorder. OCD and social phobia are also likely to occur with BDD. Psychopharmacologic treatment as well as cognitive therapy treatments have been found to be effective in the treatment of BDD. Very few studies, however, have been conducted to clarify which elements of cognitive-behavioral therapy are the most useful in the treatment of this disorder.

The following is a case description of the treatment of an 18 year old female with BDD and Major Depression. This case was further complicated by the presence of an Axis II diagnosis. "Sara" reported that she found the selection of food in the college cafeteria unappealing and subsequently restricted her intake. Already thin, she lost weight. She became depressed about her social life and demonstrated few resources to deal with situations which differed from what she expected. In this context, she picked at a pimple on her face which healed into a small, barely perceptible scar. This mark became the source of significant distress for this patient, resulting in many hours of checking it in the mirror, disguising it with make-up and fearing that her friends would see it. Her distress crescendoed into a suicidal gesture which resulted in hospitalization. The patient sought treatment at the Beck Institute after her discharge from the hospital. Initially, treatment included educating both the patient and her parents about BDD. The patient developed a series of coping cards which addressed upsetting automatic thoughts prompting her to want to check the mark on her face. The coping card included the upsetting automatic thought, the cognitive distortion inherent in the AT, and an adaptive alternative response. The patient was instructed to read these cards three times per day.

As I looked into Sara's core beliefs, I found that she believed she was defective. Her typical compensatory strategies were perfectionism. "If I get perfect grades/appear perfect to others, I'll be okay. If not, I'm defective." Sara's rigid, all-or-nothing thinking led her to equate the scar with defectiveness and the absence of facial marks with perfection. We worked together to expand her latitude of acceptable imperfections and to acknowledge that all people have imperfections. The patient could readily accept the notion of others having imperfections but was slow to accept this about herself.

During the course of her treatment at the Institute, I observed that Sara's focus on her mark increased when her core belief became activated. We explored the notion that the mark presented a means of avoiding the more painful thoughts that resulted in the patient's feeling defective. Sara and I looked together at the concerns that had arisen during her freshman year of college; mainly, these included social difficulties and issues of caring for herself. We normalized these concerns and addressed them with a problem-solving approach. The goal here was to provide the patient with tools to confront head-on the issues which had contributed to her depression and body dysmorphic disorder.

By the end of treatment, Sara was functioning significantly better. She was holding down a full-time job, eating a more balanced diet, and conducting a social life. Sara was infrequently checking the mark, and reported more positive feelings about herself. She was looking forward to returning to college and resuming her studies during the following semester.


Phillips, K.A., McElroy, S.L., Keck, P.E., Pope, H.G., & Hudson, J.I. (1993). Body Dysmorphic Disorder: 30 Cases of Imagined Ugliness. American Journal of Psychiatry, 150, 302-308.

Psychiatrists may be able to help image-obsessed
By Cindy Starr, Post staff reporter

Bron : http://www.cincypost.com/living/image031400.html

Nearly all members of the human race have had occasion to fret about their appearances from time to time. Who among us has not endured the now infamous ''bad hair day?'' What teen has not suffered a complexion meltdown just in time for an important soiree? And who among the 40-plus have not sighed in dismay as the laws of gravity and time work their inevitable will on the corpus disintegratus?

But for most of us, even our most unsightly moments are bearable. We suffer them, forget them and move on. Often we even laugh at ourselves in hindsight.

But for men and women with body dysmorphic disorder, the flaws they perceive in their appearance are not bearable, are not funny and will not be go away. People with BDD can become obsessed with a nose they are convinced is askew or with facial blemishes that others would need a magnifying glass to discern. They might think constantly about their teeth or their hair. They might check themselves in mirrors constantly, or shun mirrors altogether. Their pain might become so severe that they cannot go to school, cannot face their friends, cannot leave their homes.

''I think most people have some concerns about their appearance, but their concerns don't cause distress and don't impair their function,'' said Dr. Susan McElroy, director of the biological psychiatry program at the University of Cincinnati's College of Medicine. ''Body Dysmorphic Disorder causes distress and does impair the person's function.

''It's a secret disorder, and it's often not properly diagnosed. These people go to plast ic surgeons and xxx dentists. They're the ones who have three nose jobs. They make tr ips to the dermatologist for acne they don't have. They are tortured, functionally impaired by concerns with their appearance. They are obsessed with an aspect of their appearance which they find unattractive, ugly, repulsive - despite the fact that it's not.''

Often, she said, the psychiatrist is the last doctor the person with BDD sees. Sometimes those suffering from BDD are so depressed they commit suicide.

A significant amount of research has been done in the area of BDD in adults, but UC's Department of Psychiatry is now taking part in a study aimed at adolescents and teen-agers. The mean age of onset of the disorder is 16, and children as young as 11 have been known to have BDD.

UC is seeking teens with BDD to participate in the study.

Researchers hope to learn whether adolescents suffering from BDD can be helped by fluoxetine, or Prozac, an antidepressant that enhances serotonin activity.

Prozac has been found to help adult patients with BDD as well as those with obsessive-compulsive disorder, which bears similarities to BDD and whose sufferers typically engage in anxious, repetitive and ritualistic behaviors.

BDD is more common than one might guess. One nonclinical sample found an incidence of 2 percent, and psychiatrists have found an incidence of 4 percent among medical outpatients and 11 percent among dermatology patients, according to Dr. Brian McConville, director of child psychiatry research at UC.

''We're not entirely sure of its prevalence in adolescents,'' he said. ''It's at least equal to that found in adults and could be more, when you consider that adolescents are very concerned with the way they look.''

Indeed, a recent national survey of more than 4,000 girls found that nearly half were not satisfied with their bodies, 35 percent had considered plastic surgery and nearly 20 percent had considered liposuction, according to Ann Kearney-Cooke, director of the Cincinnati Psychotherapy Institute in Kenwood and a scholar with the Partnership for Women's Health at Columbia University.

''We were shocked that 35 percent have considered plastic surgery,'' said Ms. Kearney-Cooke. ''These are girls whose bodies are not even formed yet. That was troubling to us.''

Of course, not all adolescents who are dissatisfied with their bodies are suffering from BDD. They may be demonstrating normal adolescent self-centeredness or simply responding to popular culture's obsession with beauty. If they are among the 25 percent of Americans under age 19 who are overweight or obese, they may be struggling to cope with a very real health issue and the loss of self-esteem that so often accompanies it.

BDD ranges from mild to extreme, Dr. McElroy said, and those with true BDD have a distorted self-image:

''They really think they're hideous.''

Parents should be concerned if adolescents become so obsessed with their appearance that they avoid social events or balk at going to school.

In his memoir, ''Everything in its Place'' (Penguin, $22), TV personality Marc Summers, who has obsessive-compulsive disorder, writes about an 11-year-old girl, Darcie, with whom he appeared on a segment of ''The Oprah Winfrey Show.'' Darcie was terrified of germs and routinely checked electrical outlets and switches because of an unnatural fear of fire. In addition to having symptoms of obsessive-compulsive disorder, Darcie also showed signs of body dysmorphic disorder. Summers quotes her as saying:

''I get stuck in the mirror and have a hard time getting out.''

Feeling good about your physique

In our image-centered culture, many people are unhappy with their body shape. Those who suffer from extreme obsession may need psychiatric help. Those who endure milder disgruntlement may benefit from the following tips:

Make a list of people you admire; good looks are not a gauge of self-worth.

Question the motives of the fashion industry; the average female model weighs 23 percent less than the average U.S. woman.

Focus on healthy eating; add more fruits and vegetables to your diet.

Exercise regularly. Exercise improves mood.

Concentrate on your strengths. Keep a journal of your feelings.

Value your dollars. Spend money on products that portray women in a positive ligh t.

Voice your opinions. Talk back to your TV. Write a letter to an advertiser.

Challenge young people to develop their own ideals of beauty and handsomeness bas ed on their genetics, not on ideals presented in the media.

Remind adolescents about normal physical development. A female will grow 10 inche s and gain 30 to 40 pounds during adolescence.

Sources: Ann Kearney-Cooke, Eating Disorders Awareness and Prevention, Inc.

Terug naar indeling achtergrondsinformatie