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Body Dysmorphic Disorder And Criteria

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Body Dysmorphic Disorder And Criteria

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Diagnostic criteria
Body Dysmorphic Disorder (BDD) is a psychotic condition amidst the phenomenology of an intense engrossment with imagined or low deficiency in physical impression which are often undetectable to others. It leads to vital pain and damage in societal, personal and occupational functioning, (ref). BDD can occur to people of any age. Although it is relatively common in both males and females, females tend to catastrophize on anomalies with hips, breasts and hair and men more on muscular size, hair thinning and genitals, (ref).
BDD victims have a disfigured body image that associates with oppressing or exploitation during childhood or puberty. Such patients have a reduced standard of living, are socially secluded, miserable, and at utmost risk of committing self-destruction.These characteristics are reportedly consistent cross-culturally with a study by Fukuda, 1977 on Japanese patients with BDD, Neziroglu & Yaryura-Tobias, 1993 on American medical students, Veale, Boocock, et al., 1996 on British patients with BDD, and Tacqui et al. 2007 on Pakistani medical students.
Across age variables, a recent systematic review by Phillips et al. (2005), revealed the weighted prevalence of BDD amongst adolescents was estimated at approximately 2% in the general community and 6-14% in psychiatric settings. By comparison, adults with BDD were reported at about 2% in the general population and 5% to 8% in psychiatric settings (*).The characteristics are prolonged mental distress endured by an individual with a self-perceived physical defect, like scarring, the size of a body part, or some other personal feature (ref DSM5). 
The perceived defect or anomaly may, or may not be imagined, with a more straightforward focus on facial features (ref), but can also involve dissatisfaction with musculature (muscle size or group), or genitals, (particularly in males). The reclassification of BDD in the DSM5 from the DSM-1V has aligned the disorder from its original association with more somatoform disorders to be a collective of the Obsessive-Compulsive (OCD) and Related Disorders chapter.
Mental health experts have praised this reclassification as a significant refinement, underpinning the high comorbidity rates of this disorder with Acquisitive Neurotic Disorder, Major Depressive Disorder, and Social Panic Disorder, and thus limiting misdiagnosis (*). For example, a new and further diagnostic criteria were included to separate BDD from Social Anxiety Disorder and depression concerning continual actions or mental acts as a critical characteristic, namely trichotillomania (hair pulling), denounciation (skin picking) and hoarding disorder (Krebs& Le Cruz p2*).
In contrast to OCD, BDD fixations are not often connected with perception into the mindless of these acts but involve frequent delusional or overvalued ideation. It may simultaneously focus on several body parts (Sobanski ****20). Thus, two insight specifies were included to help clinicians identify meaningful subgroups of BDD as delusional dysmorphic beliefs as opposed to assigning a separate diagnosis of a delusional disorder, such as schizophrenia that may lead to inappropriate treatment with antipsychotic medication (ref).
A current question of controversy is whether BDD in its severest delusional form can achieve psychotic quality. The second clinically significant marker is the muscle dysmorphia specifier. It describes a preoccupation with an insufficient muscular build, to which males are particularly prone, and thus they become subjects in higher rates of steroid and substance abuse and suicide. If a little personal anomaly exists, the individual’s distress is uncontrolled. (*2).  
Diathesis-stress presentation of BDD suggest the disorder stems from the cooperation between predisposing biological elements and environ pressure (Krebs et al.). Twin studies show that xenogeneic aspects such as inheritance contribute approximately 44% of the variance in symptoms of BDD, with the remainder accounted for by non-shared environmental influences, (ref).
The most notable period of the onset of the symptomology of the disorder is reportedly commensurate with adolescence. They encounter extreme levels anguish and degree of useful deterioration and suicidal missions. Studies of Bjornssen, Didie & Grant, (2013) report a mean age of 16 for males and females, (Bjornssen, Didie & Grant, 2013. These behaviours result in repetitive skin picking, excessive grooming, and hours of mirror gazing, persistent reassurance seeking and avoidant–type behaviours (Krebs&De La Cruzpg2).. It can be the most significant essential giver to the adolescents’ self-esteem and body image associated with less favourable evaluation. (Windheim*****).
The sufferer through prolonged negative comparison in the mirror shifts their focus of attention inwards and begins a process of viewing themselves as aesthetic objects that in turn activate negative beliefs about the importance of appearance regarding their self-worth (***** 556). Depression becomes chronic and functional impairment in academic performance, reduced insight, fewer employment capabilities, more social dysfunction and more social isolation ensues (*).
Increased levels of isolation flow into all, (if not most) of the sufferers social and intimate situations, leading to major depression and other disorders with acquired narcissistic tendencies valuing other personal qualities to compensate for the perceived physical flaw (Kenny, Knott, & Cox, 2012). Cognitive associations of self-loathing, poor self-imagery and false beliefs are the everyday norm and have been found to coincide with negative environmental factors and peer abuse, with differential effects with personality type. (****20).
A recent study by Phillips (2005), found approximately 80% of individuals with BDD suffer significant anxiety with suicidal thoughts and with one in four sufferers attempting suicide due to BDD symptoms alone (ref). A study by Hartmann, Greenberg, and Wilhelm revealed that suicidal thoughts by sufferers of BDD are 25 times higher than the general population, and if comorbid with Post Traumatic Stress Disorder, increases the rate of suicide to six times that of the general population, (ref).
Mental health clinicians have undertaken several studies and found the most empirically supported, efficacious treatments available for this disorder are Cognitive Behavioral Therapy (CBT) and pharmacological prescription of serotonin reuptake inhibitors (SRI’s).
Studies of Wilhelm et al. 1999, Wilhelm et al. 2014, Rosen et al. 1995 and McKay et al. 1997, have found a successful reduction in symptom severity and related conditions such as major depression, using a combination of CBT and pharmacological therapy techniques. Thus, patients have different options available than to opt for painful and expensive surgical and dermatological treatments. 
CBT is a psychological therapy that entails teaching the development of cognitive coping strategies for BDD sufferers, by the processes of engagement and relearning how to recognize irrational thoughts and change negative thinking patterns (**). Therapy begins with an assessment of the client and associated symptoms, followed by psycho-education where the psychologist explains and individualizes the CBT model of BDD (****** Hartman, 1). It involves the use of Socratic questioning, identifying maladaptive thoughts, evaluating them and generating alternative thinking (*****2). The Socratic questioning explores the development and maintenance of the disorder in each client, through a discovery of the biological, sociocultural and psychological factors.
It is essential for the clinicians to directly ask the client about BDD related symptoms, as this disorder often goes undetected due to client feelings of intense shame and embarrassment (******2).. Progressively through the procedure, the client will undergo exposure and response prevention (ERP) technique, where therapist and client jointly develop a hierarchy of anxiety-provoking and avoidant situations as a repetitive exercise for extinguishing fear-provoking situations (ref). Many studies report the efficient and efficaciousness of ERP with BDD patients in CBT therapy. ERP reportedly aids the client to move through the debilitating anxiety and fear stages, to the next phase of healthy transpiring self and other perceptual assessments in cognitive schema restructuring.
BDD patients. For example, self-defeating interpretations are formed such as, “If my nose is too big, I am unlovable,” that provoke shame, sadness and anxiety. Dysfunctional behaviors are united with self-defeating interpretations. Thus, selective attention and attending to minor aspects of the perceived defect, for example, a perceived nose size abnormality, form instead of appreciating a holistic profile or asymmetry. CBT proves efficacious primarily with focusing on the catastrophizing of clients with BDD. It readdresses the maladaptive cognitive schemas by providing verbal, (positive and neutral interpretations), and behavioral tools, (ERP and reduction in repetitive behaviors strategies). These tools help the client to re-think the meaning and importance of this perceived physical imperfection (ref).
In adult society, six randomized controlled trials (RCTs) have shown CBT to be effective in minimizing BDD rigidity juxtaposed with no consideration or waitlist control afflictions, sympathetic therapy, and anxiety control. It also reinforces common attitude to physical appearance and body image. Such achievements can be relayed by proper comprehension the method underlying the enhancement and conservation of BDD and its healing.
Pharmacotherapy is reportedly very successful in reducing symptoms of hypomania, depression, and anxiety and can provide a stable platform from which a BDD sufferer can quickly receive a prescription from a general practitioner and feel well enough to engage a therapist via referral. Pharmacotherapy includes antidepressant medication such as SSRI’s (serotonin reuptake inhibitors) that reduce neurological stress and provide relief from obsessive-compulsive thoughts and behaviors associated with this disorder.
The first vital process of treatment is to enlist the sufferer and have adequate of an association that he or she wants to try treatment. It can be problematic to achieve, as various victims are misconceptional, are repudiation sensitive, desire cosmetic medication, or do not want other individuals (including a clinician) to watch them because they are so “ugly”. In light of the positives discussed with CBT and pharmacotherapy, there is much discussion and research to be done, to estimate the efficient and effective duration of each stage of CBT.
Before 2008, research on BDD sufferers was developed on evasive process or studies performed on children and adolescents, (Greenberg in Prazeres pg2 ***). Thus, studies published onwards from 2008 until 2012 focus on adult participants with a prime discovery of BDD according to the DSM-111, DSM111R, and DSM-1V and mainly evaluate the implications of cognitive behavioral strategies in combination with other therapies across efficacy and efficiency levels of treatment responders.
Controlled studies by Rosen et al., Veale et al., and McKay et al., found significant improvement in the reduction of BDD in individuals who undertook cognitive behavioral group therapy and exposure and response prevention (ERP) over an 18-22 week trial., (ref).
Eighty percent of final participants reported significant improvement in treatment gains and client satisfaction held at the three-month follow-up stage. This seems to suggest that continued follow up periods and perhaps more extended periods of treatment are more beneficial to sufferers but may be economically less viable or affordable for the client, and more time consuming for clinicians. Consequently, Rosen et al., (1995) did the first controlled study that positively evaluated the effectiveness of group CBT in the medication of 54 diagnosed patients with BDD.
Patients participated in strategies of mitigation of internal thoughts related to body dissatisfaction, curbing narcissistic tendencies of self-appraisal, subjection to avoided conditions about body image, and ERP for the removal of body checking obligation, (ref).  Post-treatment measures and follow up revealed 77 to 82% of all patients that participated held significant results in decreased symptoms (***pg6). A study by Khemlani-Patel et al. (2011) evaluated whether the addition of cognitive strategies improved the treatment response for BDD suffers, by assigning 10 participants to 4 weeks of cognitive treatment followed by four weeks of ERP.
 The results established that patients reported statistically noteable decreases of BDD, anxiety, and depression, though did not automatically see their appearance as being remarkably different (the Defect Related Beliefs Test), (ref). Professional viewpoints on this study argued that CBT is as productive as behavioral therapy alone, but does not certainly enhance treatment outcomes for sufferers (***8). To address this argument, a systematic study by Rabiei et al. (2012) examined the concept of metacognition within CBT strategies.  Metacognition is the process, ‘of treating beliefs simply as mental processes by modifying metacognitive thoughts about appearance and rituals, minimizing levels of self-focused rumination and expanding adaptive coping strategies,’ (Rabiei et al. ***7).
Williams et al., (2006) conducted two extensive Meta-analysis to investigate whether a combination of CBT and pharmacotherapy is more effective in treatment for BDD. The first Meta-analysis judged six pharmacological and nine psychotherapy case studies and randomized clinical experiments published between 1994 and 2003.  The pharmacological treatments were clomipramine, desipramine, fluvoxamine, fluoxetine and citalopram and the psychotherapy treatments were cognitive therapy, ERP, and CBT.  The overall outcomes tended to favor CBT as slightly more positive and productive than pharmacotherapy (***8), possibly due to providing longer-term survival strategies.
Similarly, controlled studies of CBT and ERP combined have been reviewed as potentially effective treatments, but in different forms.  Victims who present comorbidity BDD with various personality disorders respond better to ‘modular’ CBT involved with role-playing, and CBT with psychosocial rehabilitation and SSRI’s (*****pg9). However, results are mixed amongst other studies, some that debate ERP alone without CBT can produce similar significant findings in comorbid patients (*****9), and other studies found ERP without cognitive components was not active (Campisi, 1996).
A study by Dunai et al., (2010) examined executive function (EF) in BDD and found patients show deficiency in EF related to spatial working memory and subsequent thinking rate.  Results on the Stockings of Cambridge test in assessing spatial planning ability indicated that higher level planning capabilities are significantly less, and problem-solving speed markedly slower in BDD, and OCD sufferers, (*******DUNAI 1547). However, this study was ambiguous concerning measuring bias and factors of emotion, concentration and environment, to gauge a more accurate finding of planning capability.
Feusner et al., 2009, studied inverted face handling in patients diagnosed with BDD, ‘as face processing is an essential task of the brain underscored by how crucial it is for societal functioning,’ (pg Dunai 1089). This study reported abnormal data processing might underscore the apparent delusions of perceived deformities found in BDD, as distinct from OCD”, (Feusner*******pg1088). In light of BDD compulsions being primarily focused on individual or smaller details of body anomalies, compared to an eating disorder that is focused on the sum of all body parts, the characteristic of aesthetical individuals was examined. Aesthetically is the sensitivity of aesthetic perception, (Harris et al.), facial discrimination abilities and problem-solving, (Thomas and Goldberg, 1995).
Many of the case studies to date that effectively controlled for bias revealed positive results for the efficaciousness of CBT in both individual and group therapies (Veale et al., 2014, Harison et al.).  Efficaciousness means the relationship between two or more sovereign research categories that have found successful remedy trials of CBT for DBB to be better to a no treatment or waitlist category. Of note, effect sizes for comparisons of BDD with depression, OCD and delusions revealed CBT produced significant results for both main symptoms of BDD and associated features.
However, although the case studies are methodologically heterogeneous, the controlled case studies were restricted to comparisons of patients with a ‘wait list’ group of participants that were not subjected to active treatment (******9). Therefore, the results of the treatment may not be slowly afforded to the type of treatment undertaken, but results of some extent of the secondary effect providing motivation and gaining better insight.
Phillips et al., 2013 reported that the results of a naturalistic four-year potential follow up of 166 BDD case, resulted in the progrssive probability of being in full cancellation at 0.2 %. In a further analysis by Phillips, Hart, and Menard, (2014), confidence intervals ranged from 40% to 54% of outpatients categorized as respondents, or have responded to treatment and maintained relative wellbeing outside the clinician-client environments. This is reportedly substantially lower than success rates for responders of CBT with OCD patients being 60 to 80%, (depending on how the response is defined).  Consequently, reviewing parts of CBT and associated therapy is further needed to more closely identify the specific proactive components of CBT that reduce BDD
Treatment options for BDD victims who do not acknowlege to SSRI’s is also an area unknown and underexplored by research and most psychological therapies for BDD have not been researched closely except in small case series (***10). Research is somewhat stunted regarding generalization across populations and replicability, thus, limited by the minimum number of studies, small sample sizes and restrictive inclusive basis, (Wilhelm et al., 2011). Thus, only provisional conclusions could be drawn from current research, with most studies not reporting on the medication used during treatment which a significant limitation was considering SSRI’s are indicated as efficacious for BDD.
Further research
Veale’s et al., 2014 study has been reviewed as the only study to date that used a genuinely credible control treatment, the Anxiety Management (AM) outpatient setting versus the CBT group. Therefore, supplemental trials are needed to test for selectivity of CBT for BDD (Harrison & Le Cruz, 49). Veale concluded that CBT is, ‘an effectual intercession for people with BDD, even with illusional thoughts or sadness, (Veale et al, 2010) and as such, developed a non-automatic for modular personal CBT for BDD to clear up some ambiguity in previous literature, and to provide a stable framework for clinicians to treat the disorder.
While CBT is reportedly an effective medication for BDD, long-term maintenance of the positive effects of treatment has yet to be achieved in any study. Such progress requires deeper research into the ways repressing the development and conservation of the disease, with avenues found to extend evidenced-based remedy outcomes to a wider population of sufferers unable to afford prolonged professional or individualized treatment.
The current consideration of a therapist-guided stepped internet-based CBT may move treatment into a more affordable and available arena. Comparatively, as the main characteristics of BDD are profound insight, depression, isolation and avoidance, the transition to an on-line treatment is an essential and current avenue for social engagement well worth considering. It can also provide a channel for closed group sessions (i.e., collectively organized groups by a CBT clinician and explicitly tailored for BDD subgroups) to provide longevity in affordable treatment options and referrals
Extensive research will need to examine whether online treatment is actually useful in improving motivation (Miller and Rollnick, 2002), socialization and avoidant and aversive behaviors in BDD sufferers. In conclusion, there are still wide-reaching implications to be addressed and examined within CBT for BDD research. 

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