RI Hospital: Cognitive behavioral therapy benefits patients with body dysmorphic disorder

Patients reported considerable improvements in symptoms and disability PROVIDENCE, R.I. – In a recent study, researchers at Rhode Island Hospital found significant benefits of cognitive behavioral therapy as a treatment modality for patients with Body Dysmorphic Disorder (BDD). BDD is a common, often severe, and under-recognized body image disorder that affects an estimated 1.7 percent to 2.4 percent of the population. This study demonstrated significant improvement in patients' BDD symptoms and level of disability, as well as high levels of patient satisfaction with the treatment. The study is published online in advance of print in the journal Behavior Therapy. Researchers first developed the manualized treatment and then studied 36 adults with BDD who were randomly selected to either receive 22 cognitive behavioral therapy (CBT) sessions over 24 weeks, or placed on a 12-week wait list. Assessments were conducted pre-treatment, monthly, post-treatment and at three- and six-month follow-up appointments. Post-treatment, patients reported high satisfaction with the treatment, and BDD symptoms such as depression; insight regarding inaccurate beliefs about appearance; and disability in work, social life/leisure, and family life/home responsibilities significantly improved. "BDD is a common and often debilitating disorder, and there are very few proven effective treatments," said Katharine Phillips, M.D., director of the Body Dysmorphic Disorder program at Rhode Island Hospital, "This study suggests that using cognitive behavioral therapy that specifically targets BDD symptoms can result in significant improvements in symptoms and ability to function in daily life. We are currently conducting a study, funded by the National Institute of Mental Health, to more definitively test this treatment and compare it to the most commonly received type of therapy for BDD." CBT uses standard core elements relevant to all BDD patients, such as psychoeducation, cognitive interventions, exposure to avoided situations (which are usually social situations), and prevention of excessive repetitive behaviors (such as mirror checking or compulsive grooming). Treatment ends with relapse prevention strategies and booster sessions focused on helping patients maintain the gains they have made during treatment. Optional treatment modules focus on symptoms and behaviors that some, but not all, patients with this disorder engage in (such as compulsive skin picking or surgery seeking), which enables clinicians to tailor the treatment to individual patient needs. BDD typically starts during early adolescence. The disorder consists of intrusive, time-consuming preoccupations about perceived defects in one's physical appearance (for example, acne, hair loss, or nose size) whereas the perceived flaws are actually minimal or even nonexistent in the eyes of others. Individuals with BDD may engage in obsessive grooming, skin picking or plastic surgery (which appears to usually be ineffective). BDD also often leads to social impairments, missed work or school and difficulty forming and maintaining meaningful relationships. It is associated with high lifetime rates of psychiatric hospitalization and suicide. "Cognitive behavioral therapy is an often-helpful approach to treating BDD," Phillips said. "It can be tailored to meet the needs of a wide range of patients and includes unique strategies to address symptoms that distinguish BDD from other disorders." Phillips continued, "While more research is needed, we conclude from this study that CBT is an appropriate, feasible, and very promising alternative treatment for those suffering from this often misunderstood and severe mental illness." ### The study was funded in part by the National Institute of Mental Health (R34 MH070490). Phillips' principal affiliation is Rhode Island Hospital, a member hospital of the Lifespan health system in Rhode Island. She is also a member of the Department of Psychiatry and Human Behavior at The Warren Alpert Medical School of Brown University. Other researchers involved in the study were Elizabeth Didie of Rhode Island Hospital and the Alpert Medical School; and Sabine Wilhelm, Jeanne M. Fama, Jennifer L. Greenberg and Aparna Keshavia of Massachusetts General Hospital; Ulrike Buhlmann of the Institute of Psychology, Humboldt-Universität zu in Berlin, Germany; and Gail Steketee of Boston University. About Rhode Island Hospital Founded in 1863, Rhode Island Hospital in Providence, R.I., is a private, not-for-profit hospital and is the principal teaching hospital of The Warren Alpert Medical School of Brown University. A major trauma center for southeastern New England, the hospital is dedicated to being on the cutting edge of medicine and research. Last year, Rhode Island Hospital received more than $55 million in external research funding. It is also home to Hasbro Children's Hospital, the state's only facility dedicated to pediatric care. For more information on Rhode Island Hospital, visit http://www.rhodeislandhospital.org, follow us on Twitter @RIHospital or like us on Facebook http://www.facebook.com/rhodeislandhospitalpage. For more information on this and other mental health related topic, please visit MHC Continuing Education

Most Children with Rapidly Shifting Moods Don’t Have Bipolar Disorder

Relatively few children with rapidly shifting moods and high energy have bipolar disorder, though such symptoms are commonly associated with the disorder. Instead, most of these children have other types of mental disorders, according to an NIMH-funded study published online ahead of print in the Journal of Clinical Psychiatry on October 5, 2010. Background Some parents who take their child to a mental health clinic for assessment report that the child has rapid swings between emotions (usually anger, elation, and sadness) coupled with extremely high energy levels. Some researchers suggest that this is how mania—an important component of bipolar disorder—appears in children. How mania and bipolar disorder are defined in children is important because rapid mood swings and high energy are common among youth. Furthermore, many experts believe that overdiagnosis and misdiagnosis of bipolar disorder in youth may play a role in the increasing numbers of children being diagnosed with and treated for bipolar disorder. In choosing proper treatment, it is important to know whether children with rapid mood swings and high energy have an early or mild form of bipolar disorder, or instead have a different mental disorder CADC I & II Continuing Education In the Longitudinal Assessment of Manic Symptoms (LAMS) study, Robert Findling, M.D., of Case Western Reserve University, and colleagues assessed 707 children, ages 6-12, who were referred for mental health treatment. Of the participants, 621 were rated as having rapid swings between emotions and high energy levels, described as "elevated symptoms of mania" (ESM-positive). Parents of the other 86 children did not report rapid mood swings. These participants were deemed ESM-negative. Results of the Study At baseline, all but 14 participants had at least one mental disorder, and many had two or more. Attention deficit hyperactivity disorder (ADHD) was the most frequent diagnosis, affecting roughly 76 percent in both the ESM-positive and ESM-negative groups. However, only 39 percent were receiving treatment with a stimulant, the most common medication treatment for ADHD, at the start of the study. Only 11 percent of those with rapid mood swings and high energy (69 out of 621) and 6 percent of those without these symptoms (5 out of 86) had bipolar disorder, meaning that only this small percentage had ever experienced a manic episode, as defined by the current diagnostic system. Of the children with rapid mood swings and high energy, another 12 percent (75 children) had a form of bipolar disorder that includes much shorter manic episodes. Compared to children without rapid mood swings and high energy, those with these symptoms: Reported more symptoms of depression, anxiety, manic symptoms, and symptoms of ADHD Had lower functioning at home, school, or with peers Were more likely to have a disruptive behavior disorder (oppositional defiant disorder and/or conduct disorder). Significance Given that 75 percent of ESM-positive youth did not meet the diagnostic criteria for any bipolar disorder, the researchers suggest that bipolar disorder may not be common among children who experience rapid swings between emotions and high energy levels. Nevertheless, children with these symptoms experience significant impairments due to mood and behavior problems. The researchers also noted that ESM-positive and ESM-negative youth were prescribed psychotropic medications—including antipsychotics—at similar rates. Further study may provide insight into how serious mental illnesses should be treated in children. What's Next The study participants will be re-assessed every 6 months for up to 5 years, allowing the LAMS researchers to determine which children with rapid mood swings and high energy develop bipolar disorder later in life. Such research may inform efforts to identify early markers or predictors of the illness as well as possible protective factors. Reference Findling RL, Youngstrom EA, Fristad MA, Birmaher B, Kowatch RA, Arnold E, Frazier TW, Axelson D, Ryan N, Demeter CA, Gill MK, Fields B, Depew J, Kennedy SM, Marsh L, Rowles BM, Horwitz SM. Characteristics of Children With Elevated Symptoms of Mania: The Longitudinal Assessment of Manic Symptoms (LAMS) Study. J Clin Psychiatr. Epub 2010 Oct 5.