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Body dysmorphic disorder

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Body dysmorphic disorder
SpecialtyPsychiatry, psychomotor education, clinical psychology Edit this on Wikidata

Body dysmorphic disorder (BDD) (previously known as Dysmorphophobia[1] is sometimes referred to as body dysmorphia or dysmorphic syndrome[2]) is a (psychological) Somatoform disorder in which the affected person is excessively concerned about and preoccupied by a perceived defect in his or her physical features (body image). Depending on the individual case, BDD may either be a somatoform disorder or part of an eating disorder or both: BDD always includes a debilitating or excessive fear of judgement by others, as is seen with social anxiety, social phobia and some OCD problems; or alternately may be a part of eating disorders such as anorexia nervosa, bulimia nervosa and compulsive overeating. Although the term "body dysmorphic disorder" itself describes only those excessive social acceptance fears that relate to one's personal body image. Depending on the individual it may or may not also be part of one of these wider or related syndromes.

The sufferer may complain of several specific features or a single feature, or a vague feature or general appearance, causing psychological distress that impairs occupational and/or social functioning, sometimes to the point of severe depression and anxiety, development of other anxiety disorders, social withdrawal or complete social isolation, and more.[3] It is estimated that 1–2% of the world's population meet all the diagnostic criteria for BDD (Psychological Medicine, vol 36, p 877).

The exact cause(s) of BDD differ(s) from person to person. However, most clinicians believe it could be a combination of biological, psychological and environmental factors from their past or present. Abuse and neglect can also be contributing factors.[4][5]

Onset of symptoms generally occurs in adolescence or early adulthood, where most personal criticism of one's own appearance usually begins, although cases of BDD onset in children and older adults is not unknown. BDD is often misunderstood to affect mostly women, but research shows that it affects men and women equally.[6]

The disorder is linked to significantly diminished quality of life and can be co-morbid with major depressive disorder and social phobia, also known as chronic social anxiety. With a completed-suicide rate more than double than that of major depression (three to four times that of manic depression), and a suicidal ideation rate of around 80%, BDD is considered a major risk factor for suicide.[7] A person with the disorder may be treated with psychotherapy, medication, or both. Research has shown cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) to be effective in treating BDD.[8]

BDD is a chronic illness and symptoms are likely to persist, or worsen, if left untreated.

Overview

The Diagnostic and Statistical Manual of Mental Disorders defines body dysmorphic disorder as a somatoform disorder marked by a preoccupation with an imagined defect in appearance which causes clinically-significant distress or impairment in social, occupational, or other important areas of functioning. However, BDD may involve an actual defect that's slight, but the sufferer constantly obsesses over it. The individual's symptoms must not be better accounted for by another disorder; for example weight concern is usually more accurately attributed to an eating disorder.

The disorder generally is diagnosed in those who are extremely critical of their mirror image, physique or self-image, even though there may be no noticeable disfigurement or defect. The three most common areas that those suffering from BDD will feel critical of have to do with the face: the hair, the skin, and the nose. Outside opinion will typically disagree, and may protest that there even is a defect. The defect exists in the eyes of the beholder, and one with BDD really does feel as if they see something there that is defective.

People with BDD say that they wish that they could change or improve some aspect of their physical appearance even though they are generally of normal or even highly attractive appearance. Body dysmorphic disorder causes sufferers to believe that they are so unspeakably hideous that they are unable to interact with others or function normally for fear of ridicule and humiliation about their appearance. This can cause those with this disorder to begin to seclude themselves or have trouble in social situations. More extreme cases may cause a person to develop Love-shyness, a (chronic avoidance of all intimate relationships). They can become secretive and reluctant to seek help because they fear that others will think them vain or because they feel too embarrassed. It has been suggested that fewer men seek help for the disorder than women.[9]

Ironically, BDD is often misunderstood as a vanity-driven obsession, whereas it is quite the opposite; people with BDD do not believe themselves to be better-looking than others, but instead feel that their perceived "defect" is irrevocably ugly or not good enough. People with BDD may compulsively look at themselves in the mirror or, conversely, cover up and avoid mirrors. They typically think about their appearance for at least one hour a day (and usually more), and in severe cases may drop all social contact and responsibilities as they become a recluse.

A German study has shown that 1–2% of the population meet all the diagnostic criteria of BDD, with a larger percentage showing milder symptoms of the disorder (Psychological Medicine, vol 36, p 877). Chronic low self-esteem is characteristic of those with BDD, because the assessment of self-value is so closely linked with the perception of one's appearance.

BDD is diagnosed equally in men and women, and causes chronic social anxiety for its sufferers.[10]

Phillips & Menard (2006) found the completed-suicide rate in patients with BDD to be 45 times higher than that of the general United States population. This rate is more than double that of those with clinical depression and three times as high as that of those with bipolar disorder.[11] Suicidal ideation is also found in around 80% of people with BDD.[12] There has also been a suggested link between undiagnosed BDD and a higher-than-average suicide rate among people who have undergone cosmetic surgery.[13]

Signs and symptoms

There are many common symptoms and behaviors associated with BDD. Often, these symptoms and behaviours are determined by the nature of the BDD sufferer's perceived defect; for example, use of cosmetics is most common in those with a perceived skin defect. Due to this perception dependency, many BDD sufferers will only display a few common symptoms and behaviors.

Symptoms

Common symptoms of BDD include:

  • Obsessive thoughts about (a) perceived appearance defect(s).
  • Obsessive and compulsive behaviors related to perceived appearance defect(s) (see section below).
  • Feeling self-conscious in social environments; thinking that others notice and mock their perceived defect(s).
  • Strong feelings of shame.
  • Avoidant personality: avoiding leaving the home, or only leaving the home at certain times, for example, at night.
  • Inability to work or an inability to focus at work due to preoccupation with appearance.
  • Decreased academic performance (problems maintaining grades, problems with school/college attendance).
  • Problems initiating and maintaining relationships (both intimate relationships and friendships).
  • Repetitive behavior (such as constantly (and heavily) applying make-up; regularly checking appearance in mirrors; see section below for more associated behavior).
  • Note: any kind of body modification may change one's appearance. There are many types of body modification that do not include surgery/cosmetic surgery. Body modification (or related behavior) may seem compulsive, repetitive, or focused on one or more areas or features that the individual perceives to be defective.

Compulsive behaviors

Common compulsive behaviors associated with BDD include:

  • Compulsive mirror checking, glancing in reflective doors, windows and other reflective surfaces.
  • Alternatively, an inability to look at one's own reflection or photographs of oneself; also, the removal of mirrors from the home.
  • Attempting to camouflage the imagined defect: for example, using cosmetic camouflage, wearing baggy clothing, maintaining specific body posture or wearing hats.
  • Use of distraction techniques: an attempt to divert attention away from the person's perceived defect, e.g. wearing extravagant clothing or excessive jewelry.
  • Compulsive skin-touching, especially to measure or feel the perceived defect.
  • Becoming hostile toward people for no known reason, especially those of the opposite sex, or same sex if same-sex attracted.
  • Seeking reassurance from loved ones.
  • Self-harm
  • Comparing appearance/body parts with that/those of others, or obsessive viewing of favorite celebrities or models whom the person suffering from BDD wishes to resemble.
  • Compulsive information-seeking: reading books, newspaper articles and websites that relate to the person's perceived defect, e.g. hair loss or being overweight.
  • In extreme cases, patients have attempted to perform plastic surgery on themselves, including liposuction and various implants with disastrous results.

source: The Broken Mirror, Katharine A Philips, Oxford University Press, 2005 ed

Social effects

The effects of BDD can range from slightly cumbersome to severely debilitating. It can make normal employment or family life impossible. Those who do have regular employment or carry family responsibilities would almost certainly find life more productive and satisfying without BDD. The partners and family of sufferers of BDD may also become involved and suffer greatly, sometimes losing their loved one to suicide.

Studies have shown a positive correlation between BDD symptoms and poor quality of life. An indicator of just how seriously this disorder can affect a human being is the fact that the quality of life for individuals with BDD has also been shown to be poorer than for those with major depressive disorder, dysthymia, obsessive–compulsive disorder, social phobia, panic disorder, premenstrual dysphoric disorder and post-traumatic stress disorder.[14]

Because the onset of BDD typically lies in adolescence, an individual's academic and/or social performance may be significantly affected. Depending on the severity of symptoms, an individual may experience great difficulty maintaining grades and attendance or, in severe cases, may drop out of school and not reach full (academic) potential. The vast majority of people with BDD (90%) say that their disorder impacts on their academic and/or occupational functioning,[12] while 99% say that their disorder impacts on their social functioning.[12]

Despite a normal (or even strong) desire for relationships with other people, many BDD sufferers will instead choose isolation rather than risk being rejected or humiliated (due to their perceived appearance) in social interaction. Many people with BDD also have coexisting social phobia and/or avoidant personality disorder, making the sufferer's ability to establish relationships even more difficult.

Sufferers of BDD may often find themselves getting almost 'stuck' in procrastination - in some cases, they therefore appear to take a long time to get everything done. However, contrary to the usually low self-motivation, it is common to exhibit a fanatic and extreme approach when the action is relevant to the person's image, fully applying attention to the tasks at hand and at self-grooming and/or modification.

Common locations of perceived defects

In research carried out by Dr. Katharine Philips, involving over 500 patients, the percentage of patients concerned with the most common locations were as follows;

source: The Broken Mirror, Katharine A Philips, Oxford University Press, 2005 ed, p56

People with BDD often have more than one area of concern.

Comorbidity

There is a high degree of comorbidity with other psychological disorders, often resulting in misdiagnoses by clinicians. Research suggests that around 76% of people with BDD will experience major depressive disorder at some point in their lives,[15][citation needed] significantly higher than the 10–20% expected in the general population. Around 37% of people with BDD will also experience social phobia[15] and around 32% suffer from obsessive–compulsive disorder.[15] The most common personality disorders found in individuals with BDD are avoidant personality disorder and dependent personality disorder, which conforms to the introverted, shy and neurotic traits usually found in BDD sufferers.

Eating disorders, such as anorexia nervosa and bulimia nervosa, are also sometimes found in people with BDD (both in men and women), as are trichotillomania, dermatillomania, and sub-type disorders Olfactory Reference Syndrome and muscle dysmorphia.[15]

Cause

BDD usually develops in adolescence, a time when people are generally most sensitive about their appearance. However, many patients suffer for years before seeking help. An absolute cause of body dysmorphic disorder is unknown. However, research shows that a number of factors may be involved and that they can occur in combination.

Some of the theories regarding the cause of BDD are summarized below.

Biological/genetic

  • Chemical imbalance in the brain: An insufficient level of serotonin, one of the brain's neurotransmitters involved in mood and pain, may contribute to BDD. Although such an imbalance in the brain is unexplained, it may be hereditary.

Serotonin is thought to have a role in regulating anxiety, though it is also thought to be involved in such processes as sleep and memory function.

Serotonin belongs to the neurotransmitter class of molecules that transfer (chemical) signals between nerve cells. Upon a trigger, the relevant neurotransmitter is released into the neural synapse and must then bind to the receptor sites located on the neighboring nerve cell. It is hypothesized that BDD sufferers may have blocked or damaged receptor sites that prevent serotonin from functioning to its full potential.[16] This theory is supported by the fact that many BDD patients respond positively to selective serotonin reuptake inhibitors (SSRIs) – a class of antidepressant medications that prevent serotonin re-uptake from the neural synapse, thus generating higher local levels of serotonin.[16] There are cases, however, of patient's BDD symptoms worsening from SSRI use.[16] Imbalance in levels of other neurotransmitters, such as Dopamine and Gamma-aminobutyric acid, have also been proposed as contributory factors in the development of BBD.[16]

  • Genetic predisposition:

It has been suggested that certain genes may predispose an individual to developing BDD. This theory is supported by the fact that approximately 20% of people with BDD have at least one first-degree relative, such as a parent, child or sibling, who also has the disorder.[17] It is not clear, however, whether this is genetic or due to environmental factors (i.e. learned traits rather than inherited genes). Twin studies suggest that the majority, if not all, mental disorders are influenced, at least to some extent, by genetics and neurobiology, although no such studies have been conducted specifically for BDD.[17]

  • Brain regions:

A further biologically-based hypothesis for the development of BDD is the presence of abnormalities in certain brain regions. Magnetic resonance imaging (MRI)-based studies found that individuals with BDD may have abnormalities in brain regions similar to those found in OCD.[18]

  • Visual processing:

While some believe that BDD is caused by an individual's distorted perception of his or her actual appearance, others have hypothesized that people with BDD actually have a problem processing visual information. This theory is supported by the fact that individuals who are treated with SSRI's often report that their defect has gone—that they no longer see it. However, this may be due to a change in the individual's perception, rather than a change in the visual processing itself.[19] (Countering this hypothesis is, also, the fact that, if BDD were caused by an 'organic' visual information processing anomaly, this would mean the BDD sufferer would perceive other people distorted as well; no 'defect' would thus remain, compared to the assumed-normal population.)

  • Obsessive–compulsive disorder.

BDD often occurs with OCD, where the patient uncontrollably practices ritual behaviors that may literally take over his or her life. A history of, or genetic predisposition to obsessive–compulsive disorder may make people more susceptible to BDD.

  • Generalized anxiety disorder.

BDD may co-exist with generalized anxiety disorder. This condition involves excessive worrying that disrupts the patient's daily life, often causing exaggerated or unrealistic anxiety about life's circumstances, such as a perceived flaw or defect in appearance, as in BDD.

Psychological

  • Teasing or criticism:

It has been suggested that teasing or criticism regarding appearance could play a contributory role in the onset of BDD. While it is unlikely that teasing causes BDD (since the majority of individuals are teased at some point in their life), it may act as a trigger in individuals who are genetically or environmentally predisposed; likewise, extreme levels of childhood abuse, bullying and psychological torture are often rationalized and dismissed as "teasing," sometimes leading to traumatic stress in vulnerable persons.[20] Around 60% of people with BDD report frequent or chronic childhood teasing.[20]

  • Parenting style:

Similarly to teasing, parenting style may contribute to BDD onset; for example, parents who either place excessive emphasis on aesthetic appearance, or disregard it at all, may act as a trigger in the genetically-predisposed.[20]

  • Other life experiences:

Many other life experiences may also act as triggers to BDD onset; for example, neglect, physical and/or sexual trauma, insecurity and rejection.[20]

Environmental

  • Media:

It has been theorised that media pressure may contribute to BBD onset; for example, glamour models and the implied necessity of aesthetic beauty. However, BDD occurs in all parts of the world, including isolated areas where access to media is limited or (practically) non-existent. Media pressure is therefore an unlikely cause of BDD, although it may act as a trigger in those already genetically predisposed or could worsen existing BDD symptoms.[21]

Personality

Certain personality traits may make someone more susceptible to developing BDD. Personality traits which have been proposed as contributing factors include: [22]

Since personality traits among people with BDD vary greatly, it is unlikely that these are the direct cause of BDD. However, like the aforementioned psychological and environmental factors, they may act as triggers in individuals.[22]

Diagnoses

According to the DSM IV, to be diagnosed with BDD, a person must fulfill the following criteria:

  • "Preoccupation with an imagined or slight 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)."[23]

In most cases, BDD is under-diagnosed. In a study of 17 patients with BDD, BDD was noted in only five patient charts, and none of the patients received an official diagnosis of BDD.[24] This under-diagnosis is due to the disorder only recently being included in DSM IV; therefore, clinician knowledge of the disorder, particularly among general practitioners, is not widespread.[25] Also, BDD is often associated with shame and secrecy; therefore, patients often fail to reveal their appearance concerns for fear of appearing vain or superficial.[25]

BDD is also often misdiagnosed because its symptoms can mimic that of major depressive disorder or social phobia.[26] and so the cause of the individual's problems remain unresolved.

Many individuals with BDD also do not possess knowledge or insight into the disorder and so regard their problem as one of a physical rather than psychological nature; therefore, individuals suffering from BDD may seek cosmetic treatment rather than mental health treatment.

Treatment

Studies have found that Cognitive Behavior Therapy (CBT) has proven effective. In a study of 54 BDD patients who were randomly assigned to Cognitive Behavior Therapy or no treatment, BDD symptoms decreased significantly in those patients undergoing CBT. BDD was eliminated in 82% of cases at post treatment and 77% at follow-up.[27]

Due to believed low levels of serotonin in the brain, another commonly used treatment is SSRI drugs (Selective Serotonin Reuptake Inhibitor). 74 subjects were enrolled in a placebo-controlled study group to evaluate the efficiency of fluoxetine hydrochloride (Prozac); patients were enrolled in a 12-weeks, double-blind, randomized study. At the end of treatment, 53% of patients responded to the fluoxetine.[28] In extreme cases patients are referred for surgery as this is seen as the only solution after years of other treatments and therapy.

Prognosis

Many individuals with BDD have repeatedly sought treatment from dermatologists or cosmetic surgeons with little satisfaction before finally accepting psychiatric or psychological help. Plastic surgery on these patients can lead to manifest psychosis, suicidal tendencies or never-ending requests for more surgery. [29][30] Treatment can improve the outcome of the illness for most people; some may function reasonably well for a time and then relapse, while others may remain chronically ill. Outcome without therapy has not been researched, but it is thought the symptoms persist unless treated.[citation needed]

Epidemiology

Studies show that BDD is common in not only non-clinical settings but clinical settings as well. A study was performed on 200 people with DSM-IV Body Dysmorphic Disorder, being of age 12 or older and being available to be interviewed in person. They were referred by mental health professionals, friends and relatives, non-psychiatric physicians or responded to advertisements. Out of the subjects, 53 were receiving medication, 33 were receiving psychotherapy, and 48 were receiving both medication and psychotherapy.

The severity of BDD was assessed using the Yale–Brown Obsessive Compulsive Scale modified for BDD, and symptoms were assessed using a Body Dysmorphic Disorder Examination Sheet. Both tests were designed specifically to assess BDD. The results showed that BDD occurs in 0.7–1.1% of community samples and 2–13% of non-clinical samples. 13% of psychiatric inpatients were diagnosed with BDD.[31] Some of the patients initially diagnosed with obsessive-compulsive disorder (OCD) had BDD, as well.

53 patients with OCD and 53 patients with BDD were compared on clinical features, comorbidity, family history, and demographic features. Nine of the 62 subjects (14.5%) of those with OCD also had BDD.[32]

History

The disorder was first documented in 1886 by the researcher Morselli, who dubbed the condition "Dysmorphophobia". BDD was recognized by the American Psychiatric Association in 1987, and was recorded and formally recognized as a disorder in 1987 in the DSM-III-R.

In his practice, Freud had a patient who would today be diagnosed with the disorder: Russian aristocrat Sergei Pankejeff (nicknamed "The Wolf Man" by Freud himself in order to protect Pankejeff's identity), had a preoccupation with his nose to such an extent it greatly limited his functioning.

See also

References

  1. ^ Berrios G E, Kan CS (1996). "A conceptual and quantitative analysis of 178 historical cases of dysmorphophobia". Acta Psychiatr Scand. 94 (1): 1–7. doi:10.1111/j.1600-0447.1996.tb09817.x. PMID 8841670. {{cite journal}}: Unknown parameter |month= ignored (help)
  2. ^ Odom, Richard B.; Davidsohn, Israel; James, William D.; Henry, John Bernard; Berger, Timothy G.; Clinical diagnosis by laboratory methods; Dirk M. Elston (2006). Andrews' diseases of the skin: clinical dermatology (10th ed.). Saunders Elsevier. ISBN 0-7216-2921-0.{{cite book}}: CS1 maint: multiple names: authors list (link)
  3. ^ American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (text revision). Washington, DC: Author
  4. ^ Didie, E.R., Tortolani, C.C., Pope, C.G, Menard, W., Fay, C., & Phillips, K.A. (2006). Childhood abuse and neglect in body dysmorphic disorder. Child Abuse & Neglect, 30, 1105-1115
  5. ^ Neziroglu, F., Khemlani-Patel, S., & Yaryura-Tobias, J.A. (2006). Rates of abuse in body dysmorphic disorder and obsessive compulsive disorder. Body Image, 3, 189-193
  6. ^ Katharine A Phillips. Body dysmorphic disorder in men Psychiatric treatments are usually effective. BMJ. 2001 November 3; 323(7320): 1015–1016. PMCID: PMC1121529 [1]
  7. ^ Hunt TJ, Thienhaus O, Ellwood A. The mirror lies: body dysmorphic disorder.Am Fam Physician. 2008 Jul 15;78(2):217-22.PMID 18697504
  8. ^ Phillips KA.Body dysmorphic disorder: clinical aspects and treatment strategies.Bull Menninger Clin. 1998 Fall;62(4 Suppl A):A33-48.PMID 9810776
  9. ^ Phillips, K. A. (1996). The broken mirror Understanding and treating body dysmorphic disorder. p141 New York: Oxford University Press.
  10. ^ http://www.lipo.com/Health_Articles/Lifestyle_Articles/When_the_mirror_lies_-_Body_dysmorphic_disorder_(dysmorphophobia)_on_the_rise_and_taking_lives./
  11. ^ Suicidality in Body Dysmorphic Disorder: A Prospective Study. Phillips and Menard 163 (7): 1280. Am J Psychiatry
  12. ^ a b c Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p119 New York: Oxford University Press.
  13. ^ Cosmetic surgery special: When looks can kill – health – 19 October 2006 – New Scientist
  14. ^ Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p130 New York: Oxford University Press.
  15. ^ a b c d Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p391 New York: Oxford University Press.
  16. ^ a b c d Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p162–164 New York: Oxford University Press.
  17. ^ a b Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p164–165 New York: Oxford University Press.
  18. ^ Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p165–167 New York: Oxford University Press.
  19. ^ Phillips, K. A. (1996). The Broken Mirror Understanding and treating body dysmorphic disorder. p195–197 New York: Oxford University Press.
  20. ^ a b c d Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p170–173 New York: Oxford University Press.
  21. ^ Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p176–180 New York: Oxford University Press.
  22. ^ a b Phillips, K. A. (1996). The broken mirror Understanding and treating body dysmorphic disorder. p173–175 New York: Oxford University Press.
  23. ^ American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, 468 Washington, D.C.: Author.
  24. ^ Rosen JC; Reiter, Jeff; Orosan, Pam (1995). "Cognitive-behavioral body image therapy for body dysmorphic disorder". Journal of Consulting Psychology. 63: 263–9. doi:10.1037/0022-006X.63.2.263.
  25. ^ a b Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p39 New York: Oxford University Press.
  26. ^ Phillips, K. A. (1996). The Broken Mirror: Understanding and treating body dysmorphic disorder. p47 New York: Oxford University Press.
  27. ^ Orosan, P., Reiter, J., Rosen, J. (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63(2), 263-269.
  28. ^ Phillips KA, Albertini RS, Rasmussen SA (2002). "A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder". Arch. Gen. Psychiatry. 59 (4): 381–8. doi:10.1001/archpsyc.59.4.381. PMID 11926939. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  29. ^ Phillips KA, Dufresne RG (2002). "Body dysmorphic disorder: a guide for primary care physicians". Prim. Care. 29 (1): 99–111, vii. PMC 1785389. PMID 11856661. {{cite journal}}: Unknown parameter |month= ignored (help)
  30. ^ http://www.veale.co.uk/bddrefs.html
  31. ^ Phillips, K. A., Menard, W., Fay, C., & Weisberg, R (2006). "Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder". Pyschomatics. 46 (4): 317–25. doi:10.1176/appi.psy.46.4.317. PMC 1351257. PMID 16000674.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  32. ^ Phillips KA, Gunderson CG, Mallya G, McElroy SL, Carter W (1998). "A comparison study of body dysmorphic disorder and obsessive-compulsive disorder". J Clin Psychiatry. 59 (11): 568–75. PMID 9862601. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  • Sabine Wilhelm (2006). Feeling Good about the Way You Look: A Program for Overcoming Body Image Problems. New York: The Guilford Press. ISBN 1-57230-730-7.
  • Phillips, Katharine A. (2005). The broken mirror: understanding and treating body dysmorphic disorder (Revised and Expanded ed.). Oxford [Oxfordshire]: Oxford University Press. ISBN 0-19-516719-8.
  • Barlow, David (2005). Essentials of Abnormal Psychology (with CD-ROM) (4th ed.). Belmont, CA: Wadsworth Publishing. ISBN 0-495-03128-3.
  • Neziroglu F, Roberts M, Yayura-Tobias JA (2004). "A behavioral model for body dysmorphic disorder". Psychiatric Annals. 34 (12): 915–20.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  • Phillips KA (1 September 1991). "Body dysmorphic disorder: the distress of imagined ugliness". Am J Psychiatry. 148 (9): 1138–49. PMID 1882990.
  • Cherry Pedrick; James Claiborn (2002). The BDD Workbook: Overcoming Body Dysmorphic Disorder and End Body Image Obsessions. Oakland, Calif: New Harbinger Publications. ISBN 1-57224-293-0.{{cite book}}: CS1 maint: multiple names: authors list (link)
  • Phillips KA (2004). "Body dysmorphic disorder: recognizing and treating imagined ugliness". World Psychiatry. 3 (1): 12–7. PMC 1414653. PMID 16633443. {{cite journal}}: Unknown parameter |month= ignored (help)
  • Phillips, Katharine A.; Castle, David J. (2002). "Body dysmorphic disorder". Disorders of Body Image. Hampshire: Wrightson Biomedical. ISBN 1-871816-47-5.{{cite book}}: CS1 maint: multiple names: authors list (link)
  • Grant JE, Kim SW, Crow SJ (2001). "Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients". J Clin Psychiatry. 62 (7): 517–22. PMID 11488361. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  • Phillips KA, Nierenberg AA, Brendel G, Fava M (1996). "Prevalence and clinical features of body dysmorphic disorder in atypical major depression". J. Nerv. Ment. Dis. 184 (2): 125–9. doi:10.1097/00005053-199602000-00012. PMID 8596110. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  • Perugi G, Akiskal HS, Lattanzi L; et al. (1998). "The high prevalence of "soft" bipolar (II) features in atypical depression". Compr Psychiatry. 39 (2): 63–71. doi:10.1016/S0010-440X(98)90080-3. PMID 9515190. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  • Zimmerman M, Mattia JI (1998). "Body dysmorphic disorder in psychiatric outpatients: recognition, prevalence, comorbidity, demographic, and clinical correlates". Compr Psychiatry. 39 (5): 265–70. doi:10.1016/S0010-440X(98)90034-7. PMID 9777278.
  • Phillips KA, McElroy SL, Keck PE, Pope HG, Hudson JI (1993). "Body dysmorphic disorder: 30 cases of imagined ugliness". Am J Psychiatry. 150 (2): 302–8. PMID 8422082. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)

Further reading

  • Westwood, S. 'Suicide Junkie' Living and surviving body dysmorphic disorder, borderline personality, self harm and suicide. 2006
  • Saville, Chris. "The Worried Well." Body Dysmorphic Disorder. Films for the Humanities & Sciences, Princeton, NJ. 1997. Video Archive. 2004.
  • Walker, Pamela. "Everything You Need To Know About Body Dysmorphic Disorder." New York: The Rosen Publishing Group, Inc., 1999.
  • Phillips, Katharine A. (1996). The broken mirror: understanding and treating body dysmorphic disorder. Oxford [Oxfordshire]: Oxford University Press. ISBN 0-19-508317-2.
  • Thomas F. Cash Ph.D., "The Body Image Workbook, 2nd. ed.", New Harbinger Publications, 2008
  • Veale, David and Willson, Rob. "Overcoming Body Image Problems including Body Dysmorphic Disorder": Robinson, (2009)
  • The BBC documentary "Too Ugly For Love" is available from UK charity The BDD Foundation
  • TV documentary by former BDD sufferer John Furse available from Films Of Record (020 7286 0333)
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