Nezirolgu BDD Presentation Part 1

Evidence Based Treatment of Complex Body Dysmorphic Disorder
Part 1

Fugen Neziroglu, Ph.D ABBP, ABPP, Leah Frenkiel,B.A., Claudio Clavadetscher,B.A, & Douglas Fabian,B.A
.1. Body Dysmorphic Disorder (BDD) History:

  • In the late 19th century, Morselli (1891) coined the term dysmorphophobia to refer to the worries and complaints associated with an imagined deformity
  • Dysmorfia – Greek word meaning a bad body or unattractive
  • Dysmorphophobia was an obsessive idea about the deformity of the body
  • Morselli classified it as rudimentary paranoia
  • Dysmorphophobia was first cited in the American psychiatric classification in the Diagnostic and Statistical Manual for Mental Disorders III (DSM III) in 1980(American Psychiatric Association, 1980) as “atypical somatoform disorder” without any diagnostic criteria.
  • The term body dysmorphic disorder was first used in DSM III-R and continued in DSM 5.

 

  1. DSM IV-TR Diagnostic Criteria
  • Until DSM V, BDD was classified as a somatoform disorder.
  • Criteria Included:
  • Preoccupation with a perceived or imagined physical defect
  • 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. Anorexia Nervosa)
  • (American Psychiatric Association, 2000)

 

  1. Changes from DSM IV-TR to DSM V
  • Over the past decade, research has shown that BDD displays a multitude of similarities to obsessive compulsive disorder, including similarities in symptom presentation, genetic and neurobiological factors, and treatment response.
  • DSM V has recently classified BDD and an Obsessive Compulsive Related Disorder

 

  1. DSM V Diagnostic Criteria
  • Preoccupation with a perceived defect(s) or flaw(s) in physical appearance that is not observable or appears slight to others.
  • At some point during the course of the disorder, the person has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts  (e.g., comparing their appearance with that of others) in response to the appearance concerns.
  • The preoccupation causes clinically significant distress (e.g., depressed mood, anxiety, shame) or impairment in social, occupational, or other important areas of functioning (e.g., school, relationships, household).
  • The appearance preoccupations are not restricted to concerns with body fat or weight as in an eating disorder.
  • Specify if:
  • Muscle dysmorphia- form of body dysmorphic disorder (the belief that one’s body build is too small or is insufficiently muscular)
  • Specify whether BDD beliefs are currently characterized by:
  • Good or fair insight: Recognizes that BDD beliefs are definitely or probably not true, or that they may or may not be true

–         Poor insight: Thinks BDD beliefs are probably true

–         Absent insight (i.e., delusional beliefs about appearance): Completely convinced BDD beliefs are true

 

  1. Affected Brain Circuits in BDD (Feusner et al., 2010)
  • Representative slices depict activations in the right visual cortex (A), right caudate (B), right precentral and postcentral gyri (C), right anterior cingulate gyrus (D), and right orbitofrontal cortex (E).
  • Participants: 17 right-handed medication-free subjects with BDD and 16 matched healthy control subjects
  • Significant differences in regional brain activity between groups.
  • A- Regional brain activity is greater for subjects with BDD than for control subjects for normal spatial frequency own-face vs. familiar-face contrast in the caudate and left orbitofrontal cortex.
  • B- Regional brain activity is greater for control subjects than for subjects with BDD for low spatial frequency own-face vs oval contrast in the left visual cortex. L indicates left; R, right.

 

  1. Assessment Tools for BDD
  • Body Dysmorphic Disorder Examination: Self Report (BDDE-SR; Rosen, J., and Reiner, J., 1994)
  • Body Dysmorphic Scale based on Y-BOCS (BDD YBOCS; Phillips et al. 1997)
  • Body Image States Scale (BISS; Cash et al. 2002)
  • Defect-Related Beliefs Test (DRB; Butters & Cash, 1987)
  • Overvalued Idea Scale (OVI; Neziroglu et al. 1996)
  • Brown Assessment of Beliefs Scale (BABS; Eisen et al. 1998)
  • Body Dissatisfaction Checklist, a modified version of Part 1 of the Body Dysmorphic Disorder Examination Self-Report (Rosen & Reiter, 1994)

 

  1. General Demographics for BDD
  • Estimated Prevalence Rate          1-2%
  • Male-Female Ratio 1:1
  • Average Age Of Onset 16
  • Years Before First Consult 6-10

 

  1. Why BDD is Underdiagnosed:
  • Lack of awareness by clinicians
  • Omission from the SCID
  • Frequent seeking of non-psychiatric services
  • Secretiveness
  • Trivialization

 

  1. Prevalence
  • 1-2% of the general population
  • 4-5% of people seeking medical treatment
  • 7% of cosmetic surgery patients
  • 8.8-12% of dermatology patients
  • 8% of people with depression
  • More than 12% of people seeking mental health treatment

 

  1. BDD: The Severity of the Disorder
  • 29% Suicide Attempt Rate
  • 45-70% Suicidal Ideation
  • 36-58 % Hospitalization
  • 32-40% Homebound
  • 42% Full-time employment/student
  • 70% Single

(Perugi, et al., 1997; Phillips. et al., 2006; Phillips, et al., 1994; Phillips, McElroy, Keck,Hudson, & Pope, 1994)

 

  1. Quality of Life in BDD
  • BDD patients have poor quality of life across all psychosocial functioning and mental health domains.
  • BDD Patients demonstrate poorer quality of mental health life as compared to:

o       US general population

o       Patients with Major Depression or Dysthymia

o       Patients with chronic medical conditions.

  • Functioning and quality of life for BDD patients are low regardless of treatment
  • (Phillips , Menard, Fay , & Paagano, 2005)

 

  1. Risk Factors for BDD
  • Abuse History
  • Teasing
  • Past History of Dermatological Problems
  • Shyness
  • Depression
  • Anxiety
  • Perfectionism
  • Stressors in General

 

  1. Normal Concerns vs. BDD Concerns
  • Time consumption ³ 1 hour
  • Produces distress
  • Interferes with functioning

 

  1. What are commonly affected body parts in BDD?
  • Facial Features (Nose, facial skin, hair, eyes, teeth, lips, chin or ugly face in general)
  • Genitals
  • Breast
  • Buttocks
  • Abdomen
  • Hands/Feet
  • Shoulder/back
  • Any part of the body may be the focus
  • Neziroglu, F. A., & Yaryura-Tobias, J. A. (1993). Exposure, response prevention, and cognitive therapy in the treatment of body dysmorphic disorder. Behavior Therapy, 24(3), 431-438.
  1. Repetitive Behaviors in BDD
  • Clothes or hair to hide “defect”
  • Certain posture
  • Excessive make up
  • Padding
  • Mirror gazing or avoidance
  • Checking, inspecting, or measuring
  • Comparing self with others or old photos
  • Grooming, combing, smoothening, straightening, plucking, or cutting hair
  • Trying to convince others that defect exists

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