Pie Town Productions is currently casting a participant to appear on a presentation tape tackling the issue of Body Dysmorphic Disorder (BDD). This will be a thoughtful exploration of the realities of this condition and how it affects the sufferer emotionally, physically, and even socially. We are looking for someone willing to open up and discuss how the BDD is complicating his/her life.

The Show: This project is currently in development. If the series move forward, each episode will follow two separate BDD-sufferers across the country, and be a “fly-on-the-wall” in their lives. This documentary-style series would see how BDD affects the sufferer’s daily life and what steps are taken towards treatment and recovery. The mission of the show is to shed light on a topic that the public may not understand, and shatter some misconceptions about it.

Requirements for the BDD-Sufferer:

• 1 full day of shooting a presentation tape in Southern California that is NOT for air (date of shooting is fairly flexible).
• The production will follow you and see how BDD affects your everyday life.
• This might involve filming your significant other, family, or friends — whatever is applicable to your story.
• The production will want to be allowed to see part of your treatment session.
• The production will want to interview your therapist about the topic of BDD.
• If later the show moves forward with a network, and if you are interested, you may be featured on the pilot or series.

A Little About Pie Town:
Pie Town Productions was founded in 1995 and has produced over 3,200 episodes of programming in a variety of formats from daily series to network specials to weekly reality shows. Over the last thirteen+ years, their clients have included: Discovery, TLC, Paramount, A&E, WE, Lifetime Television, Logo, CMT, Discovery Heath, the Food Network, and HGTV. They’ve brought over 44 series, 36 special projects, and 1 feature documentary to the market, including the Emmy-award winning series A Baby Story. They are currently producing the new Food Network hit Chefs V. City and WE’s new family docusoap Downsized.

If you are interested in learning more or to be considered as an initial participant, please contact Dr. Yip directly:
DrYip@RenewedFreedomCenter.com or 310-268-1888.

Julie’s parents and teachers are worried. She is in the 4th grade and falling behind in her studies. Although she has a complex vocabulary, and demonstrates a high level of general knowledge, she is not performing up to her ability in the classroom. She has difficulty copying off the board, consistently falls behind in her class work, is unable to complete tests within time limits, and spends an inordinate amount of time on homework.

A doctor has diagnosed Julie with Attention Deficit Hyperactivity Disorder (ADHD). However, even after following proper treatment protocols and taking medication appropriate for ADHD, Julie shows no sign of progress. In fact, she appears even more distracted. Her parents desperately want to help her before these issues further impact her learning and self-esteem. How do we get Julie on the right track?

To get Julie on the right track, we must determine the root cause of her behavioral manifestations. In other words, we know that Julie is experiencing academic and social difficulties and appears inattentive. The question is why? The fact is that many of Julie’s symptoms can be attributed to any number of diagnoses, including ADHD, an anxiety disorder, or even giftedness. Thus, in order to put Julie on the right track, we must first accurately determine what it is that we are treating.

Is Julie’s inability to sustain attention due to her persistent distractions from worrisome thoughts? Does Julie have a hard time paying attention because she often gets bored easily? Or is Julie’s inattention due to her pure inability to attend to tasks? Each of these three possibilities gravitates toward different diagnosis. A proper diagnosis that allows for proper treatment is the first step to put Julie back on track to her full potential. On the other hand, a misdiagnosis or even a partial diagnosis – such as diagnosing ADHD alone when both ADHD and anxiety are present – can actually lead to treatment that may exacerbate Julie’s initial symptoms.

Let’s take a closer look at Julie’s symptoms, and break down the specific problems. She has difficulty completing tasks on time, such as copying from the board. Several reasons may contribute to this. For instance, an anxious child may spend a large amount of time perfecting her handwriting, checking repeatedly to see that nothing is misspelled, or writing everything on paper so that it looks exactly as the board. In particular, children with Obsessive-Compulsive-Disorder (OCD), which is a specific type of anxiety disorder, often spend an inordinate amount of time on rituals associated with writing to ensure that all the “rules” are followed exactly. They may feel compelled to make sure their handwriting slants a certain way, or erase and rewrite a certain number of times to feel “just right.”

On the other hand, a child with ADHD may have difficulty copying off of the board, because she loses focus during the lesson, and may not know what to copy. A gifted child may lose focus due to boredom, not know what to copy, and become disengaged from the classroom. The gifted child may also assume that she does not need to copy material from the board, only to realize later that she needs to reference those materials from the board. In each scenario, the simple task of copying off the board becomes a time-consuming process ultimately interfering with processing information from the lesson.

Because many anxious children spend an inordinate amount of time reviewing and perfecting their work, they fall behind. The anxious child may also doubt, and become worried that she fully understands the lesson taught, which results in time spent ruminating about a perceived ineptitude. Children with ADHD are often behind in class work because they do not work steadily on assignments to completion. The ADHD child may become distracted and start a different project, or become restless and abandon the assignment altogether. Gifted children often procrastinate; in part because they know that they generally require less time to complete projects. Unfortunately, this becomes problematic if the gifted child underestimates the time needed to complete the assignment. For the gifted child, procrastination may also signify anger for having to do the assignment, and may be a way of acting out.

Further, anxious children often disengage from lessons, because they are distracted by worries that may be unrelated to the lesson (e.g., ruminating over a poor test score just received, repeatedly checking for mistakes, mentally reviewing a previous interaction with a peer, etc.). A child with OCD, as noted above, may be fixated on a compulsion, and not be able to refocus on the material being taught. Children with ADHD are also less able to pay attention when the lesson is not interactive, or when the lesson is taught to a large classroom. For gifted children, the material being taught is often not challenging enough leading to boredom and disengagement. Nevertheless, paying little attention to the lesson plan can start a vicious cycle: The child is not engaged -> does not learn the material -> becomes discouraged because he/she now can not follow the lesson-> pays less attention/ becomes less engaged -> learns less.

We also noted that Julie often forgets her materials for projects. Anxious children may be so focused on a school project at the micro level that she becomes oblivious to the gestalt or “big picture”. For instance, an anxious child may be so completely concentrated on creating an exact replica of an Egyptian pyramid that other supplies necessary to present the project, such as note cards may be forgotton. Children with ADHD who are typically disorganized may also forget the necessary supplies. The child may even forget the homework assignment altogether if it’s not written down,. Gifted children will generally bring the proper materials to class for a project unless distracted by something more interesting.

Lastly, this case example highlights Julie’s difficulties with social interactions, specifically with making friends, leading activities, and discussing world events. Anxious children, children with ADHD, and gifted children may all have difficulties relating to their peers. Anxious children are often self-conscious and shy. They may appear introverted, because they are unsure of themselves in social settings and fear looking foolish. Some children with ADHD have under-developed social skills, which hinder their ability to interact in a way that fosters peer friendships. Also, children with ADHD are often oblivious to the social cues of others. They may blurt out inappropriate comments, and have problems waiting or taking turns. Gifted children, however, may have difficulty relating to peers, because they tend to be socially, emotionally, and or intellectually more mature and advanced than their same-aged peers. In fact, gifted children may downplay their intelligence in their struggle to make friends. Because of their emotional maturity, gifted children are also prone to mood swings.

Thus, the anxious child may be self-conscious leading an activity, because she fears making a mistake; whereas, the gifted child may be uncomfortable leading an activity due to her inability to relate to peers. A child with ADHD may not hesitate, or appear uncomfortable leading an activity; however, this child is unlikely to be effective in leadership skills due to a lack of organization and social skills.

To determine whether Julie’s discussion of world events is appropriate, we need to further explore the content of these conversations. Is Julie discussing worrisome events that concern her, such as wars, fires, or death? If so, she may be anxious. If she is discussing random world events that do not carry a theme, and she discusses them out of turn or at inappropriate times, she may have ADHD. If she discusses highly intellectual world news, and seeks to integrate her own thoughts with others’ opinions of the event, she may be gifted.

In summary, considering only the behavioral manifestation of her symptoms alone, Julie fits into several diagnostic patterns. To make the correct diagnosis, it is crucial to thoroughly explore the reasons behind Julie’s problems and understand why the behaviors occur. How can we achieve this?

• By carefully observing patterns in her behaviors and noting when they occur.
• By communicating with her parents about documenting the consistency of her behaviors.
• By coordinating with members of the school team who interact regularly with Julie.
• By framing questions, when talking directly with Julie, in a way that allow her to answer honestly without feeling ashamed.

Each of these will help to present a more thorough picture leading to the correct diagnosis. By taking these steps, we can uncover the root cause of Julie’s problems and determine the most effective treatment that will allow her to perform at her fullest potential inside and outside the classroom.

Nick was 10 years old at the time he began treatment with me. He had already been to several psychologists intermittently for talk and play therapy. He had begun seeing a psychiatrist, and was placed on a medication regimen of Luvox and Risperdal. Nick had been given various diagnoses since preschool, including Separation Anxiety, ADHD, Oppositional Defiant Disorder, Panic Disorder, and OCD. Due to his emotional outbursts and issues with anger, his family sought family therapy unsuccessfully, and was considering residential treatment at the family therapist’s suggestion. Nick also had difficulty paying attention in his classes, and always declined play dates with friends after school although he was socially interested and active during school.

When I first met Nick, he appeared to be a gentle boy with excessive fear and anxiety. He often smiled and nodded nervously in agreement with little much else to say. He expressed that his biggest fears were about being alone and “something bad happening” to him or his parents. He often worried about getting kidnapped or his parents getting into a car accident. He also had fears of contamination, and avoided any potentially contaminated items. To ensure that nothing “bad” would happen, Nick developed a set of behavioral and mental compulsions including: tapping a certain way; checking door locks, windows, stove, etc for safety measures; repeating “just kidding” to himself when he had an intrusive image of harm befalling his family; wearing the same two outfits over and over again because they felt safe.

Nick’s parents described their days as chaotic and debilitating. Getting Nick to school every morning was a struggle because of his emotional crying and pleading to let him stay home, which usually results in angry outbursts of threats. A detailed bedtime ritual of specific behaviors and words such as hugs, “goodnight” and “I love you” had to be performed in a particular way every night by each family member. If any part of the ritual was done incorrectly, it had to be repeated or Nick would have an emotional meltdown. These emotional outbursts worsened over time, and became so severe that the neighbors called the police at one time when they saw Nick jumping on the roof of his father’s car shouting “I hate you,” “I’m going to kill you,” “I want to shoot your head off.” Nick’s parents expressed waking up every morning in dread, because they felt helpless to help their child, and yet, frustrated by his unexplained behaviors.

At the outset of treatment at our program, Nick decided to call his OCD, “Mr. Worry.” Although he reported being very motivated to improve his behavior and relationship with his family, he appeared hesitant and uncertain. We developed a hierarchical list of all of the rules given by Mr. Worry. I educated Nick and his family on how Mr. Worry thrives when these rules are followed and how Mr. Worry weakens when these rules are broken.

I explained how we do not have direct control over our emotions, such as fears and anxiety, and can only redirect them through our defenses. I described how we do not have direct control over the specific thoughts going through our minds. Using his thought of being kidnapped as an example, I explained that at any given time we have a million tiny stimuli entering and exiting our minds. Helping him to understand that what we do have is “selective attention,” which allows us to focus on any one whole thought at any given time. This clarified how when we try not to think of something (i.e., getting kidnapped), we are actually selectively attending to that thought. Nick tested this theory when I said, “Now don’t think of the yellow duck.” He couldn’t, and his eyes lit up with more interest, which indicated our first breakthrough. I continued to explain that what we do have control over is our behaviors, including our actions and reactions to our thoughts and emotions. This means that we only have control over those behaviors that Mr. Worry instructs us to perform, such as checking and tapping.

From this very first psychoeducation of how OCD functions, Nick’s initial hesitation began to subside. We developed a strategy to beat Mr. Worry by selecting those rules (compulsions) to break that were at the bottom of the difficulty scale and worked our way up. Nick began acquiring tools to beat Mr. Worry by following this model:

We cannot control our emotions.
We cannot control our thoughts.
To beat Mr. Worry, we can only control our behaviors by not following his rules.

As for Nick’s behavioral outbursts, I explained to his parents how Nick himself did not comprehend what he felt. The anxiety from the obsessive fears of harm for a 10-year-old can be extreme and debilitating. Rather than feeling protected by his parents, Nick felt resentment toward them for making him go to school and experience his anxiety even more. I discouraged their consideration of residential treatment, which would only increase Nick’s resentment, and instructed them to audio tape his behavioral outbursts. This was used during sessions to increase Nick’s awareness of his emotional meltdowns. Additionally, we practiced graded exposures to his fears of being alone, such asseparating from his parents for brief moments by stepping just outside the front door for 2 minutes and taking 10-minute walks around the neighborhood.

To increase Nick’s motivation, we used a behavioral modification program for the Exposure and Response Prevention (ERP) part of treatment. This involved exposing Nick to his obsessive fears in a hierarchical level of difficulty without engaging in the compulsive behaviors. Nick was rewarded with his chosen privileges each time he was able to beat Mr. Worry and not give into the rules.

By that summer, 5 months from starting our treatment program, Nick was able to ride the school bus daily without anxiety, enjoy sleepovers at friends, participate in a weeklong camp away from home, and fly on a plane by himself. His mother even got into a minor car accident, which he stated, “was a good exposure.”

Although Nick’s behavioral symptomology may have initially appeared as ADHD or Oppositional Defiant Disorder, the underlying cause for his behaviors were clearly triggered by obsessive fears of harm to self and others, accompanied by the compulsive rituals to ensure safety. Had we entertained the other diagnoses, his symptoms would have been aggravated by the medications for ADHD, his anger would have worsened by his perception of his parents lack of understanding, and his overall functioning would have decreased by his inability to manage Mr. Worry.

At my first appointment with Dr. Jenny Yip, she handed me a list of the ten cognitive distortions. She asked me to look over the list and tell her which of them might apply to me. As I read them I felt like I was reading through a bad melodrama (“You’re so stupid, stupid, stupid!”) Clearly, none of these could apply to me; an intelligent and rational individual, or so I thought. As time went on, I slowly began to admit to one and then the next until I found myself committing them all. I was simply not noticing them and sometimes intentionally avoiding them because I felt ashamed of such blatant errors in judgment. The reality is that cognitive distortions are a part of our everyday thought process. This is something we must accept, and once we do, we are more capable of remaining mindful of them. Keeping an “automatic thought record” helps a great deal. In fact, after my recent experience, I just began keeping one again after not doing it for months. Managing an anxiety disorder is a lifelong process. If I find myself more edgy or overwhelmed than I am used to, perhaps it is time to reevaluate my present position and review and reuse the tools that I have learned along my journey.

My situation was magnified by those students that I compared myself with. I went through high amounts of emotional turmoil, because everyone from my best friend to my girlfriend seemed to have found a perfect college and I was a loser left behind. I didn’t want to go to the school I was headed to, and at the same time, all my friends could ever talk about was going away to school. This combination of perceived social pressure and my intense intrusive thoughts ruined my daily life.

Once school got out, I spent most of my time researching schools and my role models and where they went to school. I also began having excessive doubt. I doubted I could achieve my career goals at the school I was headed to. I doubted whether anyone would ever hire me from the school I was going to. Everything just was so “awful” about the school I was heading to. I stopped going outside and spent all of my time on the computer researching. Whenever my friends talked about school, I would leave, and a depression finally set in. My therapist diagnosed me with OCD about halfway through the summer, and my doctor put me on medication. All of the medication I first tried didn’t work and I finally began having suicidal ideation when the time to go to school got closer and closer. I was admitted to the hospital and stayed for two weeks. I finally saw a glimpse of hope, but alas, I was too drugged up to go to school and was forced to stay home.

All of my worst fears were occurring and all of my friends left for school. I was stuck with pain and rejection until finally my parents found Doctor Yip and Gorbis, and it felt like I finally had real help. I left for Los Angeles and Doctor Yip first started helping me deal with my Panic Disorder, employing numerous tools such as interoceptive exposures, and continuing to do so until my anxiety went down. She also started me on mindful awareness and other books to help change my black and white thinking. At the same time I started to visit campuses around the Los Angeles area and I began getting some confidence and hope. I went home for a brief period during early October and used a variety of methods to help keep my OCD and Panic levels minimized as I visited campuses back home. I then went back down to Los Angeles where I continued my treatment with Doctor Yip and Doctor Gorbis. I began using loop tape exposures to expose myself to the worst possible consequences and also gaining more tools to help treat my OCD. In the mean time I also did Social Phobia exposures where I engaged in bizarre behaviors in front of complete strangers. For example, I shaved a reverse mohawk into my hair and got what I considered flamboyant clothing and wore it around UCLA.

At the end of the program my OCD went down to a manageable level and my general anxiety went down a lot too. Doctor Yip supported me in making a college choice and the eventual psychological ramifications to knowing I was locked into a college. Since then my anxiety has gone up and my OCD has gone up, but I have done a better job knowing how to deal with my OCD and avoiding catastrophic thinking. My family and friends have also been great supports, and I can say I am living a more normal life now. Though I had to change medications, and I am still waiting for the effects to set in and help me deal with my anxiety and OCD intrusiveness the closer I get to school. Even last week I was able to visit the college I was going to attend all by myself for two days, and felt ok about going there. I have learned to feel wrong and be ok, and to not catastrophize when the anxiety comes but to embrace it. My mind still gets tunnel visioned sometimes, but I am using the tools Doctor Yip gave me and drawing on past experiences to see reality and disregard unwanted thoughts.

I still feel like I am incapable of doing things and in a largely down and out mood, but I hope with my medication and tools that I will go to college and do well. All of my OCD thoughts are the same now and they most likely won’t go away until I get to school. Meanwhile I am still on my journey, fighting for my life goals, and learning something new everyday.

Anxiety is the most common cause of mental, emotional, and behavioral problems during childhood and adolescence. However, it is often overlooked or misjudged in children and adolescents. About 13 out of every 100 children and adolescents ages 9 to 17 experience some kind of anxiety disorders. About half of children and adolescents with an anxiety disorder have a second anxiety disorder or other mental or behavioral difficulty, such as depression. If the necessary child anxiety treatment is ignored, anxiety disorders in children will likely progress into adulthood. Thus, it is foremost necessary to learn to identify the correct underlying cause of a child’s inattentiveness. A proper assessment is the first step to prevent long-term difficulties at school and minimize frustration for others involved in the child’s life. From a valid assessment, we can determine a proper diagnosis and establish an effective child anxiety treatment plan. Therefore, it is critical that parents and teachers understand the difference between anxiety disorders and ADHD in children.

Anxiety vs. ADHD

Although on the surface level Timmy’s difficulty with concentration and focus may appear to be the result of ADHD, a closer look at the clues reveal underlying causes that actually point to symptoms of anxiety that necessitate child anxiety treatment. Children with ADHD have a difficult time paying attention and focusing. They may also be impulsive and have difficulty with self-control, and be hyperactive. A child with an anxiety disorder may have symptoms that appear the same, however, the symptoms are actually behavioral manifestations of the child’s preoccupation with excessive worry, fears, and tension. Let’s take a closer look at Timmy’s specific symptoms that are caused by anxiety rather than ADHD.

• Timmy is a shy, nervous kid who prefers to keep to himself and wait for others to approach him. Children with anxiety do not always understand why they have excessive worries and catastrophic thoughts that trigger intense fears. They cannot comprehend that the experience of the internal “fight-or-flight” sensation actually serves a survival purpose. From their lack of understanding of what is going on with their mind and body, they may attribute these symptoms to “something is wrong with me.” They may purposely keep their distance from others, especially peers, to keep their “oddities” hidden and prevent others from noticing. Child anxiety treatment will help Timmy understand the difference between his subjective experience of anxiety and his objective experience of the internal “fight-or-flight” response. Anxiety treatment will also teach Timmy to evaluate his catastrophic thoughts more accurately by looking to his environment for evidence of triggers to his “fight-or-flight” experience.
• Timmy favors routine, and becomes anxious to change or when he is in a new, unfamiliar situation. Children with anxiety regularly feel apprehensive about their environment. They are constantly hyper-vigilant and on guard for any remotely potential catastrophic event to occur. They view their world as an unsafe place filled with unfamiliar and dangerous possibilities of harm, real or imagined. To maintain a sense of security and certainty, they prefer to be in familiar situations, leaving out the need to second-guess anything. When they are put in new environments, they feel intense fear about the uncertainties of their environment, and may even react with extreme temper tantrums. Child anxiety treatment will give Timmy a set of tools to manage symptoms of anxiety when he is feeling intense fear. As he becomes competent in utilizing this set of tools, he will feel more confident about approaching new environments. In turn, anxiety treatment will teach Timmy that being in unfamiliar environments does not necessarily equate to danger.
• Timmy gets bored easily, often stares out of the window, and even dozes off at times. He is frequently late to school and often complains of having headaches and feeling nausea. Children with anxiety disorders often complain that their bodies hurt, and that they feel ill. These are physical manifestations of our internal physiological sensations of anxiety. Children with anxiety may also experience tiredness from lack of sleep at night. Morning and bedtime periods tend to be more difficult than midday for anxious children, making morning routines that much more time-consuming. Although they may appear bored or distracted, anxious children are actually too preoccupied with fears and worries to participate in activities and stay on task. Instead, their minds are elsewhere and lost in their worrisome thoughts, which can negatively affect their academic performance. Child anxiety treatment will target Timmy’s inattention indirectly by first addressing his preoccupations with fear and worries. As Timmy learns to apply the tools to manage his internal physiological sensations of anxiety, he will gain the mental capacity to stay focused and will generally experience less physical manifestations of illness.
• Timmy spends an inordinate amount of time on assignments, and always needs extra time to complete assignments and tests. He is forgetful, and has problems copying off the board, sitting still, and staying on track. Children with anxiety are so consumed with their worries and fears of uncertainty and harm that they have little room in their minds for anything else. In fact, it is rather difficult to stop the train of apprehensive thoughts once the worry engine is triggered. This makes it extremely hard for anxious children who are in the midst of their worrisome thoughts to have the necessary attention span long enough to retain effective memory skills for their classroom tasks. It also makes is difficult for the anxious child to remain still and maintain calmness. As a result, the time needed to complete tasks if often prolonged. As Timmy’s ability to focus increases by addressing his apprehensive thoughts through child anxiety treatment, he will regain mental space for effective memory skills. As a result, anxiety treatment will help Timmy maintain enough calmness needed to complete tasks more efficiently.

After taking this closer examination of Timmy’s condition, it is clear that his behavioral manifestations stem from anxiety rather than ADHD, as it may have initially appeared. We now have a better understanding of his behaviors and symptoms, which actually require anxiety treatment versus ADHD treatment. Assessing for anxiety gives us a more complete perspective, allowing us to determine a proper diagnosis and establish an effective child anxiety treatment plan. Thus, learning how inattentiveness presents itself within the anxious child is the first step to gaining specific strategies for working with the child successfully within the school and with the family.

OCD typically involve other family members of the patient suffering from this disorder. It significantly interferes with family dynamics, and has a significant impact on family functioning. In addition, families play a critical role in the child’s OCD treatment readiness, compliance, recovery rate, and relapse. Thus, consideration of the familial context, developing healthy collaborative relationships among the patient, his/her family, and the therapist, and integrating the family into treatment is vital to child OCD treatment outcome, since families are an integral part of the lives of individuals with OCD.

The level of involvement families partake in the patient’s rituals varies. However, a family’s affect level can affect and is affected by OCD. For instance, a calm supportive family may improve the outcome of child OCD treatment, whereas a family that is excessively critical and overinvolved may exacerbate the symptoms in the patient. It is crucial to assess family dynamics such as these accurately for successful child OCD treatment. At minimum, one of the parents or caretaker is present throughout the child OCD treatment process, especially during the initial assessment. This allows the patient, parent, and therapist the opportunity to explore the individual’s subjective experience of OCD, as well as specific symptoms and underlying fear structures.

Following a thorough and comprehensive assessment of the patient’s obsessive fears, compulsive behaviors, and the family’s level of involvement in the patient’s rituals, comes the crucial task of psychoeducation. The purpose of psychoeducating the family is to provide a cognitive-behavioral framework of OCD, and to explain the child OCD treatment process. The most significant motivator and predictor to child OCD treatment success is to ensure that each family member understands how OCD functions within the context of the family, and how the family as a whole can defeat OCD.

Learning about OCD and its symptoms is an important first step in understanding how to defeat it. Mrs. Jones, mother of a 19-year-old adolescent who was successfully treated five years ago in our intensive treatment program, states, “Families really need to be involved in the child OCD treatment process, because they really do play a part in OCD even when they don’t realize it. Whenever I had company over, I didn’t know they were all contaminating the whole house for my son.” The family must learn such key concepts as the vicious cycle of OCD, the OCD triangle, the overappraisal of threat, harm, and danger in obsessive fears, the physiological law of habituation to a feared response, and the various cognitive errors in the interpretation of intrusive thoughts to have meanings of threat, harm, and danger.

Once the family understands how they function within the patient’s OCD cycle, family members must agree not to partake in any part of the patient’s ritualistic behaviors for successful child OCD treatment. For instance, a child with OCD probably has tried to control his/her ritualistic handwashing behavior, as well as those of other family members. Many pathological doubters seek reassurances from their parents, or ask their siblings to check door locks, stoves, cleanliness of objects, etc. more often than necessary. These repetitive behaviors often irritate those who are pulled involuntarily into the vicious cycle of OCD. In order to reduce their own frustration, family members may give in to the OCD by complying to the child’s request, which, in turn, only reinforces the obsessions and rituals.

In order to benefit from child OCD treatment, when a patient insists on involving another into his/her ritualistic behavior or reassurance seeking, the rule of thumb for the involved family member is to always courteously respond with “it’s the OCD asking”. Not only would family members detach themselves from the rituals of OCD by identifying the behavior as “OCD,” this response also helps the patient separate him/herself from the OCD, whom for many have come to identify themselves as merged with the disorder. Accordingly, Mrs. Jones affirms, “Once I understood that I was actually contributing to my Ben’s OCD, I was able to tell him that ‘it’s your OCD that’s asking me’, which also took the burden off my shoulders.”

In helping the patient manage the specific obsessions and compulsions, the family must also learn the basic principles of Cognitive-Behavioral Therapy (CBT) and more specifically Exposure and Response Prevention (ERP), which are the most effective methods for OCD treatment. The purpose of exposures is to reduce the anxiety and discomfort associated with obsessions through a process called habituation. Habituation is the natural process by which our nervous system gets “used to” or “bored by” feared stimuli through repeated and prolonged contact.

There are two types of exposures in OCD treatment: in vivo and imagery. In vivo or “real life” exposures require the patient to confront the fears in the flesh. For instance, a child may be asked to touch feared objects, such as an empty trash can or other “contaminated” objects, without alleviating the anxiety with handwashing compulsions. Through repeated practice, the patient realizes that the feared catastrophic consequence does not occur, and the initial anxiety associated with the feared situation decreases. Exposures are conducted according to hierarchical stages, in which components of anxiety are broken into smaller pieces. In child OCD treatment, we call them baby steps.

Sometimes it is impractical or impossible to create the actual feared situation in child OCD treatment, for example, the fear of developing a disease or losing a loved one. In these situations we utilize imaginal exposures, which involve prolonged and repeated visualizations of the feared image or situation along with the experience of anxiety. Variations of different scripts of imagery tapes are made and tailored to the individual’s needs and fear structures, which are then replayed continuously until the patient habituates to them.

In order for the family to understand the basics of CBT and specifically ERP in child OCD treatment, the family must be present and involved during the exposure exercises. The purpose of having family members present and involved in the process of child OCD treatment is to help them learn the tools necessary to detach themselves from obsessive-compulsive symptoms during and upon termination of the OCD treatment process.

In essence, the goal is to train family members to become therapists themselves, which also serves two other purposes. First, in order to know how to deal with OCD, one must be able to accurately identify the symptoms of OCD, which requires mindfulness. Mindful awareness training is part of the OCD treatment process, and a necessary component to child OCD treatment success. Second, since children tend to resist exposure exercises due to the discomfort they create, being present and involved in the child’s OCD treatment would reduce manipulations that the child may engage in once home. As Mrs. Jones clearly confirms, “…being involved (in treatment) forces the child into accountability and keeps him from manipulating. Ben was willing to protect OCD at all cost.”

In addition to the above guidelines for the family, the following coping strategies should be adopted for the success of any child OCD treatment:

• Don’t take OCD upon yourself. Separate yourself and family from OCD.

• Know others are out there. You are not alone. Connect with other family members for support and encouragement.

• Be cool! Use a calm manner. Reacting in frustration and distress only leads to further frustration and distress.

• Always speak clearly, calmly, and in a positive way.

• Adjust expectations realistically to reflect current circumstance. Never compare your child’s progress to anyone but him/herself.

• Encourage your child to put extra energy into enjoyable activities (i.e., exercise, listening to music, etc.).

• Redirect your own energy into enjoyable activities rather than being a slave to your child’s OCD.

• Identify rituals and compulsions for what they are, rather than participate in them.

• Go about your own business as usual. Reconnect with friends, hobbies, and family routines.

• Never be judgmental of your child’s behavior.

• Never make decisions for your child (unless a young child). Help your child build confidence by allowing your child make his/her own choices.

• Do not pressure your child to stop compulsions or restrict rituals. Just stick to tasks assigned by the therapist.

• Set the rules, limits, and boundaries clearly, and make certain your child fully understands them.

• Solve problems step-by-step. Make changes gradually. Work on one thing at a time.

Teaching and learning is the main philosophy and pillar on which our success stands, and we believe that emphasizing success and building upon it will build more success. Knowledge is power, and if there is a silver lining to OCD, it is having insight to the self, OCD, and others, and becoming more aware of the present; here and now. We must learn from our interactions with each other, as students and teachers, children and parents, patients and therapists.

“The best is for families to understand that it’s going to be tough, but when they get better, they’ll be a new person. We got Ben back who was covered underneath OCD, and I don’t think we could’ve done it without being involved and learning the tools we have” – Mrs. Jones.

Jenny C. Yip, Psy.D.
Director of Education
Westwood Institute for Anxiety Disorders, Inc.

Eda Gorbis, Ph.D., LMFT
Director
Westwood Institute for Anxiety Disorders, Inc.

Sufferers of BDD worry excessively and unreasonably about some flaw in their appearance that may be minimal or even nonexistent (Gorbis & Kholodenko 2005, Phillips et al. 1993). These excessive worries and fears prompt sufferers to ritualize their behaviors by constantly checking the supposed defects in mirrors, seeking reassurance of their images from others, obtaining unnecessary cosmetic and/or dermatological procedures, and even conducting self-surgeries (Rosen et al. 1995, Phillips et al. 2000, Veale 2000, Phillips et al. 2005). These obsessive concerns and compulsive behaviors cause significant emotional distress and often significantly interfere with global functioning (DeMarco 1998, Gorbis & Anan’Yev 2004).

By its nature, BDD is highly comorbid with other psychopathologies, including OCD or OC Spectrum Disorders (29%), Major Depression (59%), Social Phobia (35%), and Substance Use Disorders (49%) (Phillips et al. 1999, 2005). In fact, over 50% of patients suffering from BDD have reported that the emotional distress of the disorder contributed to their substance use, and more than 30% have attempted suicide at least once (Grant et al. 2005).

BDD is not simply dissatisfaction with a body image, as we all tend to complain about a crooked nose, flabby stomachs, or becoming bald, which may all be factual. In BDD, patients suffer from a body image distortion that is internalized through social factors (e.g., peer pressure, parental critique, etc.) and/or, as of yet, an undefined neurological deficit (Slaughter & Sun, 1999). This internalized misperception creates disproportionate fears in the patient, whom relieves the anxiety through compulsive behaviors, such as persistently checking the perceived flaw in mirrors and reflective surfaces.

According to Maxwell Maltz (1960), a renowned authority of plastic surgery and the father of cybernetics, the issue of self-esteem is a vital component and determinant of a person’s self-image. Patients with BDD always present with negative self-esteem, low self-confidence, and a distorted self-image. They tend to seek external validation of their self-image and self-worth, and appearance determines their self-esteem to a great extent.

Although BDD was first recognized in 1886 by the Italian physician Morselli who called it dysmorphophobia or “fear of ugliness,” only recently has this condition received much attention. Plastic surgery has become increasingly available in the last 15 years, and has been viewed with more approval and tolerance from the general public (Mulkens & Jansen 2006). In the United States, 10.2 million cosmetic surgery procedures were carried out in 2005 (American Society of Plastic and Reconstructive Surgeons (ASPS),

2006), which represents an increase of nearly 700% since 1992 (ASPS, 1992). Although cosmetic medical treatments were previously the exclusive domain of plastic surgeons, today physicians from various specialties (e.g., dermatologists, ear, nose and throat specialists, and dentists) offer such treatments (Sarwer & Crerand, 2004).

Of recent years, the media has also been paying a great deal of attention to cosmetic surgery. For instance, the reality television show, Extreme Makeovers, has people undergo a complete make-over within about six weeks while showing the before, during, and after process of multiple surgeries. The media obsessively focuses on and gossips about those celebrities who have undergone the scalpel. On a more ethical standpoint, many documentaries on the devastating condition and treatment of BDD have been broadcasted on such television programs as the Discovery Channel, MTV, 20/20, The Learning Channel (TLC), and BBC among many other news programs. Thus in general, the public may experience a much lower threshold for deciding to undergo plastic surgery due to changes in the medical community, advances in technology, and the large increase in advertisements and media attention (Sarwer & Crerand, 2004).

In January 2007, People Magazine covered the topic, “Obsessed with Plastic Surgery,” in which Eda Gorbis, Ph.D., LMFT showed how a patient suffering from BDD can be treated with her novel technique using “crooked fun house” mirrors. The goal of the crooked mirror is to externalize that internal self-image that is cognitively distorted (Gorbis 2004a, Gorbis 2003). The crooked mirror not only puts a person’s self-image into perspective, but also sheds light onto the cognitive-distortions through the use of humor. In doing so, patients learn to come to terms with themselves, accept themselves with their imperfections, and begin to rebuild a more accurate mental picture of themselves along with their flaws.

However, since sufferers of BDD are more or less convinced that the solution to their problem is to improve their image, it is to no surprise that they are also more likely to view plastic surgery as their only option to change their appearance. With the increased availability of plastic surgery, BDD patients are, nonetheless, turning to cosmetic medical treatments again and again and again. This population tends to be under-diagnosed due to the fact that few patients with BDD have come forth admitting their condition has a psychiatric cause. Rather they are increasingly turning up in offices for cosmetic procedures. However, on a caveat, few BDD patients are ever satisfied with their body image due to their unrealistic expectations of outcome triggered by the distortion of their internalized self-image.

Currently, up to 15% of cosmetic surgery patients comprise of individuals suffering from BDD. Of those who opt for cosmetic surgery, only 7.3% of all treatments lead to both a decrease in concern about the treated body part and an overall improvement in BDD. Generally following treatment, patients worry more about another body area, develop new image concerns, become more concerned about minor imperfections in the treated area, or worry that an improved body part will become ugly again (Phillips et al., 2001). In a study conducted by Veale (2000), out of 25 patients with BDD who had undergone a total of 46 cosmetic procedures, 9 patients had performed their own Do it Yourself (DIY) surgery, in which they attempted to alter their appearance themselves (e.g. by using a staple gun). Even when patients were (partly) satisfied, the preoccupation transferred to a different area of the body.

This incapacitating condition of the BDD population has not only raised concerns from the media and mental health professionals. More and more plastic surgeons are increasingly alarmed by those patients who are continuously dissatisfied and who repeatedly seek surgery for the same area(s). Recently, Michael J. Gunson, D.D.S., M.D. from the Center for Corrective Jaw Surgery in Santa Barbara sought assistance from the Westwood Institute for Anxiety Disorders, Inc. for one of his patients who appeared to be suffering from BDD. Specifically, the patient had undergone several previous jaw surgeries performed by other surgeons, which Dr. Gunson had to correct. However, although the facial features appeared adequate following Dr. Gunson’s surgery, the patient continued to be dissatisfied while purposely wrenching one side of her face as to camouflage the perceived flaw. After consulting on this particular patient and gaining more information on the severity and treatment of this population, Dr. Gunson invited Westwood Institute for Anxiety Disorders, Inc. to speak on this topic at their national annual conference for plastic surgeons. He expressed the importance of disseminating knowledge of BDD to other plastic surgeons in order to increase their awareness and ethical responsibilities of individuals suffering from this condition.

Considering the grave dangers of treating patients with BDD, it warrants necessity for plastic surgeons and other cosmetic treatment professionals to recognize these patients within their population. However, many studies indicate that preoperative psychiatric screenings are rarely performed by plastic surgeons or other cosmetic treatment professionals (Thomas,

Sclafani, Hamilton, & McDonough, 2001). The findings and expressed concerns from some plastic surgeons evidently indicate that psychiatric evaluation of this condition and the patient’s motivation for treatment should be a standard practice in cosmetic treatment settings. As the Center for Corrective Jaw Surgery has sought collaboration with Westwood Institute for Anxiety Disorders, Inc., it is essential for other medical practitioners to collaborate with mental health professionals to identify and provide appropriate treatments for patients suffering from BDD.

Eda Gorbis, Ph.D., LMFT
Director
Westwood Institute for Anxiety Disorders, Inc.

Jenny C. Yip, Psy.D.
Director of Education
Westwood Institute for Anxiety Disorders, Inc.

References

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DeMarco, L. M., Li, L. C., Phillips, K. A., McElroy, S. L. (1998). Perceived stress in body dysmorphic disorder. Journal of Nervous & Mental Disease, 186, 724-726.

Gorbis, E. (2003). Mirror, mirror on the wall. OCD Newsletter, 17, 4-14.

Gorbis, E. (2004a). Crooked mirrors: The externalization of self-image in body dysmorphic disorder. Behavior Therapist, 27, 74-76.

Gorbis, E. (2004b). Externalization as a therapeutic tool in treating BDD. OCD Newsletter, 18, 4-15.

Gorbis, E., & Anan’Yev, D. (2004). Dr. Gorbis’ intensive OCD method uses self-analytical writing. OCD Newsletter, 18, 3-8.

Gorbis, E., & Kholodenko, Y. (2005). Plastic surgery addiction in patients with body dysmorphic disorder. Psychiatric Times, 10, 79-81.

Grant, J. E., Menard, W., Pagano, M. E., Fay, C., & Phillips, K. A. (2005). Substance use disorders in individuals with body dysmorphic disorder. Journal of Clinical Psychiatry, 66, 309-316.

Maltz, M. (1960). Psycho-cybernetics. Englewood Cliffs, NJ: Prentice-Hall, Inc.

Morselli, E. (1886). Sulla dismorfofobia e sulla tafe fobia. Bolletino della Regia Accademia de Genova VI: 110-119.

Otto, M. W., Wilhelm, S., Cohen, L. S., & Harlow, B. L. (2001). Prevalence of body dysmorphic disorder in a community sample of women. American Journal of Psychiatry, 158, 2061-2063.

Phillips, K. A., Dufresne, R. G., Wilkel, C. S., & Vittorio, C. C. (2000). Rate of body dysmorphic disorder in dermatology patients. Journal American Academy of Dermatology, 42, 436-441.

Phillips, K. A., Grant, J. D., Siniscalchi, J., & Albertini, R. S. (2001). Surgical and nonpsychiatric treatment of patients with body dysmorphic disorder. Psychosomatics, 42, 504-510.

Phillips, K. A., Menard, W., Fay, C., & Weisberg, R. (2005). Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics, 46, 317-325.

Phillips, K. A., Siniscalchi, J., McElroy, L. S. (1999). Depression, anxiety, anger, and somatic symptoms in patients with body dysmorphic disorder. Psychiatric Quarterly, 75, 309-320.

Rosen, J. C., Reiter, J., Orosan, P. (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63, 263-269.

Mulkens, S., & Anita, J. (2006). Changing appearances: Cosmetic surgery and body dysmorphic disorder. Netherlands Journal of Psychology, 62, 34 – 41.

Sarwer, D. B., & Crerand, C. E. (2004). Body image and cosmetic medical treatments.

Body Image, 1, 99-111.

Slaughter, J. R., & Sun, A. M. (1999). In pursuit of perfection: A primary care physician’s guide to body dysmorphic disorder. American Family Physician, 6, 1738-42.

Thomas, J. R., Sclafani, A. P., Hamilton, M., & McDonough, E. (2001). Preoperative identification of psychiatric illness in aesthetic facial surgery patients. Aesthetic Plastic Surgery, 25, 64-67.

Veale, D. (2000). Outcome of cosmetic surgery and DIY surgery in patients with body dysmorphic disorder. Psychiatric Bulletin, 24, 218-220.

The preoccupation with food found in anorexics depicts the intrinsic obsessive nature of the eating disorder. There is a persistent preoccupation with food in a concrete way in the form of involuntary ruminative calorie counting and mental imaging of food, which is experienced as out of the individuals control (Rothenberg, 1990). Along with an obsession with food, there is also a focus on control, which is a core element in OCD.

In addition to these common symptoms, there are biological similarities as well, since serotonin dysfunction has been implicated as one of the possible causes of OCD and anorexia nervosa (Hsu, Kaye, & Weltsin, 1993). These factors have led many investigators to study the relationship between anorexia and OCD. Due to the high comorbidity and phenomenological similarities, many researchers are in favor of broadening the definition of obsessive-compulsive spectrum disorders to include eating disorders such as anorexia nervosa and bulimia.

One distinction between the two disorders is that the characteristics of OCD are ego dystonic while those of anorexia nervosa are more ego syntonic. This difference must be considered in treatment planning. Due to the complication of distorted body images of anorexics, the collaboration between various treatment professionals specializing in OCD and eating disorders is essential for the effective outcome of treatment.

Psychoeducation on appropriate diet, nutrition, exercise, and weight management is foremost important at the beginning and throughout treatment. Cognitive-behavioral therapy (CBT) that addresses abnormal thoughts and behaviors, and that aims at developing coping resources for stress management is the most effective treatment for OCD and eating disorders.

Cognitive restructuring helps to reduce negative self-image, feelings of helplessness, and negative thinking patterns. Psychotropics involving antidepressants and selective serotonin reuptake inhibitors (SSRIs) may also be considered to improve symptoms of anorexia and OCD. Group therapy provides support, and correct inaccurate self-judgments and misperceived information. Furthermore, family therapy provides support and psychoeducation to family members, and addresses underlying family dynamics, which is especially necessary if the patient is a young adolescent living with family members.

Exposure and response prevention (ERP) reduces anxiety of becoming overweight by exposing the patient to images of perceived fat. For instance, patients are instructed to wear tightly fitted clothes, listen to grossly exaggerated loop tapes of images of being overweight, write self-scripts of becoming obese, and experience feelings of fullness after meals. Patients are prevented from excessive exercise and compulsive weight checking. As with BDD, crooked mirrors are used to expose and externalize patients’ distorted internal body images.

This year, two patients with severe OCD and anorexia nervosa have come through the Westwood Institute for Anxiety Disorders, Inc in Los Angeles. One has completed treatment with significant improvements while the other is currently in treatment. Both patients were drastically underweight with life threatening conditions, in which they had to be fed through feeding tubes.

The first patient was a 16-year-old male with magical thinking, fear of gaining weight, fear of making mistakes, and fear of contamination. After breaking his jaw in a skateboard accident, his jaw had to be held up with bandages for a year, which limited his ability to move his mouth and chew. During this healing process, he was only able to feed through tubes. Since he lost weight during the year, he continued to limit his food intake even after his jaw had healed, so that he would not become fat again.

A little over a year later, he experienced a second skateboarding accident, in which he broke his leg. As a result of the two traumas that he endured within the short duration of time, he began to believe that “bad luck” was following him. Within a few months, his magical thinking increased and his obsessive concern with food and weight worsened. He began developing such compulsive behaviors as repeating, correcting, checking, washing, and perfecting. For instance, he would walk around the dinner table and chair again and again until he felt “just right,” or he would have to touch door knobs before engaging in any activity. He also developed food-related rituals, in which he would divide his food perfectly into smaller portions.

During the initial evaluation, his functioning had deteriorated to the point that it was life threatening. He had to be withdrawn from school due to his diminished capacity to concentrate. Rituals became more severe and consumed most of the day. He had lost over 40 lbs within a few months, and his blood pressure continued dropping. He was experiencing black-outs, and was unable to move out of the house. His OCD’s magical thinking was indicative of overvalued ideations, and was tightly intertwined with the anorexia. His Yale-Brown Obsessive-Compulsive Scale (YBOCS) score of 36 and Hamilton Rating Scale for Depression (HAM-D) score of 35 indicated severe OCD and depression.

Due to the severity and comorbidity of his OCD and anorexia, treatment involved 4 weeks of inpatient care at the eating disorder unit at UCLA’s Neuropsychiatric Institute and Hospital. Upon discharge, he participated in the outpatient day treatment program for another 5 weeks. The intensive CBT regimen to target his obsessive-compulsive symptoms also started simultaneously. The treatment utilized progressive exposures to feared stimuli coupled with complete response prevention. Thus, he was discouraged from engaging in all rituals in order to maximize the effectiveness of exposures. In addition to each daily session, he was given two to three hours of daily assignments that closely paralleled the skills acquired from each day’s session.

Over the course of therapy, he struggled with the treatment process. Initially, he had significant difficulties following directions in accordance to this treatment plan, and he put forth only minimal effort in daily assignments. However, toward the end of treatment, his motivation level increased substantially as his obsessional fears declined. At termination of treatment, his YBOCS and HAM-D scores were 7 and 6, respectively.

The second patient is a 14-year-old male with fear of gaining weight and fear of making mistakes. His condition was influenced by his twin brother’s obsession with “healthy food,” and precipitated by a general instruction from his track coach. Within a short period of time, his symptoms deteriorated rapidly. He began developing food rituals, in which he would use his hands to break the food into very small pieces before putting it into this mouth. This ritualistic process increased his meal times considerably, which interfered with other academic and social activities. He also began developing repetitive compulsions, such as flipping light switches, opening/closing doors, pacing up and down the stairs, and touching his face in a particular manner. These rituals had to be performed strictly to avoid “feeling uncomfortable.”

At the initiation of treatment, he was losing weight at the rate of 8 lbs/week due to his food refusal, and was down to a total weight of 87 lbs. He was deficient in electrolytes, his cardiac rate had dropped to the 40’s, and he experienced bladder and bowel retention. He reported that he was having difficulty eating due to the performance of excessive rituals during meal times. His YBOCS score of 39 indicated severe obsessive-compulsive symptoms. Due to his life threatening condition, he was admitted to the eating disorder unit at UCLA’s Neuropsychiatric Institute and Hospital. It has now been 4 weeks since his admission, and he continues to struggle with his condition, in which a feeding tube is necessary to provide him with nutrition.

On an interesting note, his twin brother has also been admitted to the eating disorder program at UCLA. The attending clinicians suspect that he also has some slight obsessive-compulsive symptoms. Specifically, he appears to have obsessive concerns involving “healthy food” that stems from fears of gaining weight and food contamination. His related rituals include reassurance seeking and checking behaviors.

Eda Gorbis, Ph.D., LMFT
Director
Westwood Institute for Anxiety Disorders, Inc.

Jenny C. Yip, Psy.D.
Director of Education
Westwood Institute for Anxiety Disorders, Inc.