Imagined Ugliness


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Key points were clarified and fascinating information was shared at an incredibly insightful presentation I attended with Noah Clyman, LCSW-R and colleagues from NYC Cognitive Therapy earlier this month, Imagined Ugliness: Understanding and Treating body Dysmorphic Disorder, given by Sabine Wilhelm, Ph. D. 

Body dysmorphic disorder (BDD), can be briefly defined as having a preoccupation with one or more perceived defects or flaws in physical appearance that is not observable or appear slight to others (Diagnostic and Statistical Manual of Mental Disorders, DSM-5). BDD usually begins during adolescence, but can occur earlier in childhood and presents almost evenly among genders.

Common physical appearance obsessions:

  • Acne
  • Body or facial hair
  • Thinning hair on head
  • Scars or markings on skin
  • Moles
  • Coloring of skin complexion
  • Wrinkles
  • Facial Asymmetry
  • Shape or size of facial features, various body parts, or muscles

Maladaptive behaviors include: mirror checking, excessive grooming, skin picking or mental acts of comparing appearance to that of others. Many patients also exhibit avoidance behavior. They may avoid places that are very appearance focused (e.g. weddings), brightly lit places and mirrors. This can lead to problems with friends, family or work (calling out, arriving late due to rituals, etc). Preoccupations cause significant distress or impairment in social, occupational or other important areas of functioning. The preoccupations are not attributable to other medical conditions or better accounted for by concerns with body fat or weight in an eating disorder. Muscle dysmorphia–a psychological disorder marked by a negative body image and an obsessive desire to have a muscular physique—is a subtype of BDD.

There are many causes of BDD:

  • environmental factors (teasing, childhood neglect/abuse, socio cultural pressures)
  • psychological factors and personality traits (perfectionist, rejection sensitivity)
  • interpretation biases and information processing abnormalities (detail oriented, self-focused, misperception of neutral facial expressions or situation as threatening)
  • biological theories (involvement of frontal-striata/amygdala brain circuitry, family history).

Associated problems include depression and/or anxiety. Alarmingly, the suicide rate for BDD patients is approximately 45 times higher than the general population.

Effective vs. Ineffective treatments

A few treatments are considered by BDD patients. Non-psychiatric treatments are often sought out, such as dermatologist or plastic surgeons. These are usually ineffective and often the patient consequently feels worse after. They can be disappointed when the desired social result is not achieved (e.g., belief that surgery will lead to having friendships, feeling confident, and so on). A significant amount (27%) of BDD patients obtain cosmetic surgery or dental procedures. Medications that are best studied are antidepressants (SRI’s: fluvoxamine and clomipramine). However, all the SRI’s appear to be effective. Typically patients who suffer from BDD require dosages at the higher end of the therapeutic range for SRI’s. Cognitive behavioral therapy, time-limited psychotherapy that modifies maladaptive thoughts, beliefs and behaviors has been proven effective.

Tips to help a friend or loved one overcome barriers to treatment:                                                                                                         

  • Don’t argue with loved one over the existence of the perceived flaw (or agree).
  • Focus on the excessive preoccupation and how it may be impairing their daily lives. In regards to discussions about surgery or dermatological treatments, start a cost/benefits conversation of strategies (consider CBT and/or medication).
  • If friend or loved one wants to drop out of CBT to get cosmetic treatment, have them consider postponing the surgery. The surgery can always be an option later, see if they are willing to try a certain number of sessions first.
  • Embarrassment about being seen in the waiting room – think of a plan to manage anxiety (arrange appointment time with practitioner so there is no waiting time with other patients).

Tips to enhance motivation for loved one or friend:

  • Look forward by asking loved one a question such as: What do you want life to look like in 5 years (what would it look like with or without CBT)? Also think of extreme scenarios (what is the best/worst case) and encourage change talk.
  • Start at the end by asking questions like: What do you want people to say about you when you aren’t here? When you look back on your life? What memories do you want to have?

Research findings

Results of a recent study (24 treatment completers): BDD Severity of sample decreased and results were sustained post treatment. The mean BDD YBOCS score (questionnaire used to measure BDD severity) was 32.5 pre treatment, 15 post treatment (week 24) and 13.5 at the 6 month follow up.

About the author:

Kaley Montgomery is a second year MSW student at New York University Silver School of Social Work. Making a career change after seven years in the fashion industry, she revisited her long standing passion to help people improve functioning in their lives and relationships. Having worked in corporate offices with a variety of companies in New York City, she understands the stress and pressure that can accompany juggling the many demands of city life. She takes a joint approach while working with clients and is an avid believer of CBT, mindfulness and meditation. To book an appointment with Kaley, visit www.nyccognitivetherapy.com.

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Making Friends with Your Anxiety


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Anxiety is a function that is built into the human nervous system, for better or for worse. Understanding that it is natural (though seldom logical, and almost never comfortable) allows space for questions such as, “What would it feel like to fully accept anxiety when it is present?” “If I stopped fighting, what would happen?” “Can I be fully present during the experience of anxiety?” If you have a strong reaction to these questions, remember that sentiment, and check to see if it still feels true at the end of this blog.

 

I am far from the first one to pose these kinds of questions. Let’s examine a story from about two millennia ago. What follows is my own paraphrasing of an old teaching parable that I believe speaks volumes to the questions at hand (remember that parables are intended to be metaphorical, not literal):

 

A king, departing for travel, tells his attendants to take care of his throne in his absence. Not long after he departs, a demon enters the castle and sits down right on the king’s throne. The attendants are horrified, and in trying to uphold their obligation, they attempt to get rid of the demon. They try yelling, fighting, screaming, pushing, bribing, ignoring, and every method they can think of to force this demon out of the throne. With each attempt he simply grows larger and stronger, until he is so massive and imposing that the attendants feel hopeless and give up, fleeing to another part of the castle.

 

When the king returns from his travels, the attendants relay to him what is waiting on his throne, explaining that they have exhausted every conceivable option for getting rid of the demon. Being a wise and experienced king, he smiles and enters the castle. “Hello demon!” he exclaims, and to the shock of the attendants, the demon begins to shrink. “It looks like you’re enjoying my throne. Feel free to stay a little longer,” the king adds, and the demon shrinks further. “Would you like a cup of tea while you’re here?” he asks, as the demon continues to shrink. With each bit of kind and skillful attention that the king pays to the demon he continues to diminish until he ceases to exist altogether.

 

Dr. Padesky from the Center for Cognitive Therapy states that anxiety is typically described as an overestimation of danger, and an underestimation of resources. She contends that in therapy the overestimation of danger often receives most of the focus, but the underestimation of resources can be a much more powerful area to explore. Facing anxiety and fear with the right skillset and guidance brings about long-term change. If someone believes they do not possess the resources to rise above anxiety, it is only because they have not yet uncovered them.

 

People often treat anxiety like a demon, attempting to get rid of it by pushing, fighting, ignoring, and suppressing. Just as in the parable, this tends to have the opposite effect. CBT teaches us that we must first learn to be aware of our thoughts and feelings, and this means we can no longer ignore or suppress them; such defenses only reinforce the cycle of anxiety and phobia.

 

People often believe anxiety is static, but in CBT we come to learn that it is actually a constantly changing series of thoughts, feelings, and behaviors. In mindfulness practice we spend time getting to know the intricacies of every experience, and we see that even intense panic is changing from moment to moment and is not a solid piece of us, but an impermanent sensory and psychological experience that can happen to anyone.

 

When anxiety evolves from something that occurs once in a while into an issue that greatly impedes someone’s life, it is often the case that the relationship with the anxiety itself has become worse than the triggers that produced the anxiety in the first place. Thoughts can seem so disturbing, feelings so distressing, and bodily sensations so uncomfortable that they are grouped into a blanket experience (dubbed anxiety), and demonized. Just as in the parable, fighting only succeeds in strengthening it by activating the sympathetic nervous system. Anxiety and fear-driven thoughts lead to more anxious feelings, which trigger more thoughts and bodily sensations, all modulated by our beliefs and assumptions, and this cycle can continue indefinitely. Anxiety cannot persist without fuel, which this cycle provides in surplus.

 

The solution lies in befriending the “demon.” While not an easy or comfortable option, it is the greatest long-term solution to anxiety. To resolve anxiety one must spend time observing it and understanding it, taking note of its components. The various thoughts, feelings, and bodily sensations that make up anxiety can be most effectively dealt with if they are experienced with mindfulness and compassion, at which point the activating cycle will be interrupted and the fuel source dissipated. This is especially true when done in a safe space with a therapist.

 

If you are interested in doing this kind of work with a therapist, feel free to contact me at 347-470-8870 extension 706, or at mikecomparetto@nyccognitivetherapy.com.


NY Times: How an Insomnia Therapy Can Help With Other Illnesses


insomnia

Did you see the NY Times article describing treatment of insomnia last week? Written by Austin Frakt on July 13, 2015. Visit the website here: http://mobile.nytimes.com/2015/07/14/upshot/how-an-insomnia-therapy-can-help-with-other-illnesses.html?_r=1&referrer=

At my group practice, NYC Cognitive Therapy, our clinicians are experienced in the theory and application of Cognitive Behavior Therapy for insomnia (not to mention a broad range of other mental health issues). Visit our website here to learn more about the problems we treat, or call today to schedule an appointment (347-470-8870).

Finally below is a blog post I wrote in August 2011 describing how CBT treats insomnia. These techniques are time-tested and durable.

Best, Noah

NoahClyman,LCSW-R, ACT

Academy of Cognitive Therapy (ACT) Diplomate & Fellow
Certified Trainer/Consultant & Credentialing Committee Member
Clinical Director, NYC Cognitive Therapy
347-470-8870, x700
Fax: 347-470-8870

 


Transform Bad Habits Into Good Ones


If you have a habit that you know isn’t great for you, perhaps you can transform it into something more beneficial.

Research on behavior change shows: If you can identify why you do something, what you’d rather be doing, and what’s stopping you from doing the more beneficial action, you can come up with a plan to transform the bad into good.
When you contemplate changing a bad habit, think about the habit in terms of the following questions. This can help you get to the root of it and inspire you to come up with better habits.
 
Ask yourself:
 
* Why do I do this thing (what reward do I get from it?)
 
* Are there any downsides to operating this way?
 
* What would I rather be doing instead?
 
* What’s stopping me from doing the thing I want to be doing?
 
* What steps could I take to get over that resistance?
 
* What benefit would I get from replacing the bad habit with a good one?
Think about what you can do to overcome the barriers to creating the habit that could place the bad one. Then take some action to get started on the new habit.
Everyday example: housecleaning
 
I’ll come clean (pun intended) and share with you that I hate cleaning my apartment. Mind you, I love having a clean house. But I don’t like the actual cleaning. So I’ve developed the bad habit of cleaning only when I need to. That’s right, I’m a reactionary cleaner. If no one’s coming over, I don’t pick up the broom or pull out the vacuum.
But I’d like that to change. I’d like to become someone who cleans regularly, without resentment, and enjoys having a clean home much of the time.
So I answered the questions above to try to transform my habit of reactionary cleaning into regular cleaning.
NEGATIVE HABIT: CLEANING ONLY IF PEOPLE ARE COMING OVER

* Why do I do this thing (what reward do I get from it?)
I’d pretty much rather be doing anything but cleaning, so if I wait until I absolutely have to do it, I clean less.

* Are there any downsides to operating this way?
The dust bunnies bother me, and sometimes I feel guilty that the apartment gets so messy. Plus I don’t feel I can have people over spontaneously.

* What would I rather be doing instead?
I’d rather hire someone to do it for me, but since I’m not willing to spend the money for that, I would like to clean on a regular basis, perhaps weekly.

* What’s stopping me from doing the thing I want to be doing?
I find cleaning unpleasant (i.e., boring and exhausting).

* What steps could I take to get over that resistance?
Once I started thinking about this, lots of things came to mind:

* I could acquire better cleaning tools, ones that make cleaning easier. (A lighter-weight vacuum, for instance.)
* I could ask my partner to do it (*sinister chuckle*). 😉
* I could work on one room, one task or one floor of my house at a time, rather than feeling like I have to clean the whole apartment at once.
* I could do more daily chores (like the wiping down of the bathroom fixtures I already do) to make weekly cleaning easier.
* I could have a professional in to help me with deep cleaning a few times a year.

* What benefit would I get from replacing the bad habit with a good one?

It was easy to come up with a list of the benefits of cleaning regularly, rather than waiting for guests to come over (or waiting until it was so awful even I couldn’t stand it).
* I would rid myself of the guilt I often feel about being a lousy housekeeper.
* Cleaning itself would be easier because I’d be doing it more often.
* I could invite people over at a moment’s notice.
* I’d live in a cleaner environment, which can only be good.
* I’d probably entertain more, because it wouldn’t be as much work.
Just realizing how many benefits there would be to changing my behavior is very motivating.
 
TAKE ACTION! 
 
Your turn: Identify a bad habit you’d like to change.
 
Some examples of habits you might want to change could be:
* Smoking
* Eating fast food, junk food or sugary foods
* Leaving items out rather than putting them away
* Over-shopping
* Being late
* Procrastinating
* Letting papers pile up
* Aimlessly watching TV
* Grocery shopping without a list
* Incessantly checking email without responding
* Aimlessly using the internet for surfing, Facebook, etc.
 
 Then ask yourself the questions outlined above. See if you can come up with a more beneficial behavior to replace your bad habit.
 
Use the message board to share your results!

Nine Secrets of Successful People


It’s human nature to compare ourselves to other people. I call this the “comparing” trap. It’s when we look at someone who’s prettier, skinnier, wealthier, funnier or any other “-ier.” Most of the time, we compare upwards, to people who we think are better off and this can make us feel inadequate. We ask, “Why is that person so lucky?,” “What does she/he have that I don’t?,” or “If only I were (stronger, had more willpower, worked harder, or fill in the blank:_______), then I could have that too.” Fortunately, there is a recipe for success. In Nine Things Successful People Do Differently, Heidi Halvorson summarizes decades of research showing that successful people reach their goals, not because they were born with certain talents (although in some fields, talent helps but doesn’t explain success) but because they do things differently. Below are nine skills that can increase your chances of success with any goal. Note these are learnable skills and within anyone’s capacity to learn.

  1. Be Specific. When setting a goal, spell out exactly what the results will look like. Have you heard of SMART goals? This stands for Specific, Measurable, Achievable, Relevant and Timely. Saying I want to start exercising is not specific enough. Instead, a SMART goal would be: “I will begin walking three times a week for 30 minutes between 8 and 8:30 am on Mondays, Wednesdays and Fridays. This is important to me because I want to reduce my cholesterol before my doctor tries to put me on medication.”
  2. Act on your Goals. How many times do you set goals and then do absolutely nothing to achieve them? The more you set SMART goals where you visualize exactly what you will do, the more you’ll be motivated to act on them. Research indicates that planning ahead (what you’ll do and how to handle obstacles) can increase your chances of success by 30%.
  3. Monitor your Progress. Research shows that the mere act of writing down a goal and tracking your progress actually creates success. Why? First, just paying attention to a goal and your habits around it will cause you to start tweaking them. Second, if you know how well you are doing, what accounted for the success so far and how much further you want to go, it’s easier to continue doing what works and changing what doesn’t.
  4. Be a Realistic Optimist. Reaching most important life goals requires time, planning, effort and persistence. If you think it will be easy and then you hit a road bump, you are more likely to get discouraged and give up. On the other hand, being as positive as possible and celebrating small steps toward your goal helps maintain motivation.
  5. Focus on Getting Better, rather than Being Good. Having a flexible, learning mindset is important because it enables you to develop and acquire new skills. Focusing on improving and learning from experience also helps minimize procrastination and self-sabotage due to perfectionism and fear of failure. Remember that life is a journey!
  6. Have Grit. Grit is the skill of learning to persist in the face of challenges and obstacles. When times get tough, you’ll be more motivated to persist if you set SMART goals that really matter and you develop a realistically optimistic attitude and a learning mindset.
  7. Flex your willpower muscles with CBTBuild your Willpower Muscle. Building willpower is also a skill you can develop. To build willpower, pick a baby step toward a moderately challenging goal and make a plan using the steps in this article to start practicing. As you prove to yourself that you do have willpower, you’ll be building your willpower muscle and it’ll be easier to flex for more challenging goals.
  8. Don’t Tempt Fate. Your willpower supply is limited so don’t put yourself in situations that are too tempting, at least not in the beginning. Work on one challenging goal at a time before moving on. Don’t make the goal harder to achieve by doing things that self-sabotage.
  9. Focus on What You Will Do, not What You Won’t Do. Figure out what good new habits you want to develop. Habits work like this: a trigger stimulates a craving and then you engage in a  series of familiar behaviors to fulfill the craving. If you want to develop a new habit, first you need to understand what you are really craving. Second, experiment with new ways to respond to the trigger that will satisfy the real craving. Third, continue practicing the new behaviors to strengthen the new habit loop.                                                                                                                                                                                                                                                                                                                              Good luck reaching your goals this year. Make 2013 the year of small goals with big results.

To vent or not to vent? That is the question.


“Am I better off expressing my anger, or should I keep it in?”

This is a question I was asked by a patient recently, which led to a stimulating discussion on the psychology of anger and tools for improving communication and regulating emotions. I was inspired to share these insights with all of you.

First, some psychoed:

Popular psychological wisdom would suggest that when you are feeling angry, you should get it all out, releasing any and all of that pent-up anger and hostility. Punch that pillow, throw your rage at a punching bag, or smash some dishes. You’ll feel better afterwards. Right?

Maybe not. As author Carol Tavris comments in her important book, Anger: The Misunderstood Emotion, “Expressing anger makes you angrier, solidifies an angry attitude, and establishes a hostile habit.” Recent clinical studies have shown that emotional catharsis (the active expression of anger and hostility by physically releasing anger) can work against you. Researchers found that when people acted out their anger this way (hitting or punching something) they felt more aggressive afterward, not less aggressive. Worse, by giving people permission not to control their feelings, the people experienced more episodes of aggressive anger in general.

Can I at least yell?

Yelling doesn’t appear to help reduce anger. Screaming, “You’re a stupid jerk and I hope you rot in hell!” to someone who has just done you wrong clearly has a lot of emotional appeal. And it may even feel pretty good in the short run. However, it may not be the best thing for your health and overall stress level. When you yell, your body becomes stressed. Your heart rate increases. We know that raising your voice, and certainly yelling, can lead to an increase your blood pressure as well. Yelling can have psychological effects as well. In one study of 535 subjects, yelling, screaming, and lashing out resulted in greater feelings of low self-esteem. Because in most cases the yelling did little to resolve the problem, the subjects felt – and were seen – as being out of control rather than taking charge and acting competently. You can be sure that yelling – and feeling out of control or incompetent – doesn’t elevate your self worth.

Should I suppress my anger?

Anger can be destructive when it steeps and simmers within you. When you keep your angry feelings inside it’s often the only thing you can think about. The anger remains fresh and you re-anger yourself over and over by ruminating about the injustice. You remain trapped with these feelings and are unable to enjoy the moment and live life well.

So what does all this mean? If your therapist is advising that you avoid yelling and also avoid suppressing, you may be wondering what’s left? My next blog post will offer several suggestions for how to deal with anger.

In the meantime, I have an assignment for you, the reader. Use the message board to share your experiences & answer the following questions:

Questions for the message board:

  • How do you deal with anger?
  • Do you lash out or keep it all inside?
  • What have you found are the results of how you express anger?
  • What do you think is the best way to deal with anger?

Cognitive Behavior Therapy (CBT) in action


Mike is a 38-year-old gay man who had suffered disabling bouts of depression, on several occasions in his life, which caused him to make several career changes. He twice tried to commit suicide. He also suffered from a great deal of anxiety and stress, occasionally binged on alcohol to cope, and found it difficult to control his temper, especially when drinking.

Mike was referred for CBT after a typical episode was triggered by stress at work. At his first meeting with his therapist, Mike already knew what he wanted to work on. He had a great sense of failure over his history of depression and what he called his lack of success in his career (“I’ve really messed up”). He was anxious about his job prospects. He felt unattractive and was worried about aging and about further losing his physical appeal. He felt his angry impulses were in danger of getting out of control.

In therapy, Mike learned to monitor his actions and his emotional responses. He began to plan activities that gave him a boost and to deal with situations that he had avoided through fear. He learned to identify when he was being extreme or biased in his thinking. He became good at examining his emotion-driven thoughts and reasoning them out so that he got things into proper perspective. His mood noticeably improved, and he began to tackle long-standing problems. He began looking at job prospects, by planning a more realistic choice of career, and sending in applications. He dealt with social situations, without demanding attention and special treatment from friends.

Mike had to face up to problems that were difficult to take on board, such as his perfectionism and the unreasonable demands he made on other people. But Mike was highly motivated by the crisis in his life to find alternatives.

This is what he wrote towards the end of his therapy:
“I have had many painful episodes of depression in my life, and this has had a negative effect on my career and has put considerable strain on my friends and family. The treatments I have received, such as taking antidepressants and psycho-dynamic counseling, have helped to cope with the symptoms and to get some insights into the roots of my problems.”

“CBT has been by far the most useful approach I have found in tackling these mood problems. It has raised my awareness of how my thoughts impact on my moods. How the way I think about myself, about others and about the world can lead me into depression. It is a practical approach, which does not dwell so much on childhood experiences, whilst acknowledging that it was then that these patterns were learned. It looks at what is happening now, and gives tools to manage these moods on a daily basis.”

“The work has moved on to look at deeper beliefs, which can dominate one’s life and cause loads of problems. For example, I have found that I have a strong entitlement belief [a belief that he is entitled to expect certain things from other people]. This is characterized by low frustration tolerance, anger, and inability to control impulses or be told what to do. It has been a revelation to look back on one’s life and see how this pattern has dominated a lot of what I have done. CBT has given me a feeling of being more in control of my life. I am now coming off medication and, with the support of my therapist and partner, I am learning new ways of being in the world. The challenge remains to change these thoughts and behaviors. It will not happen overnight.”

Mike is a man who has applied himself very actively to change. As this quotation reveals, CBT offered him much more then the “quick” fix that it is sometimes portrayed as giving.