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56. Veale, D. and Neziroglu, F. (forthcoming 2008). Body Dysmorphic Disorder: a treatment manual. Wiley, Chichester. 55. Veale, D. (in press). Cognitive Behaviour Therapy for Body Dysmorphic Disorder. In: "Handbook of Evidence Based Psychotherapy". (ed C.R. Freeman,. & M. Power). Wiley, Chichester. 54. Veale, D. and Willson, R. (2007). Manage your mood: using behavioural activation to overcome depression. Robinson publishing, London. 53. Veale, D. (2007). Psychiatric evaluation for cosmetic procedures. In: Handbook of Liaison Psychiatry. (ed G. Lloyd & E. Guthrie). Cambridge University Press. 52. Veale, D. (2006). Treating OCD in people with poor insight and overvalued ideas. In: Psychological Treatment of OCD: Fundamentals and Beyond. (eds M. Antony, C. Purdon & L. Summerfeldt). American Psychological Association. 51. National Collaborating Centre for Mental Health (2006). Obsessive compulsive disorder: the management of obsessive compulsive disorder and body dysmorphic disorder in children and adults in primary and secondary care. London: Gaskell and BPS. [Download guidelines] 50. Veale, D. (2006). A compelling desire for deafness. Journal for Deaf Studies and Deaf Education,11:369-372 [Abstract] 49. Veale, D. and Lambrou, C. (2006). The psychopathology of vomit phobia. Behavioural and Cognitive Psychotherapy,34(2) 139-150 [Abstract] 48. Veale, D. (2006). Psychological aspects of cosmetic surgery. Psychiatry.5(3): 93-95 47. Brill,S. Clark, A., Veale, D. & Butler, P.(2006) Psychological Management and Body Image Issues in Facial Transplantation. Body Image 3(1)1-15. 46. Watkins, L., Sahakian, B., Robertson, M., Veale, D., Rogers, R., Pickard, M. and Robbins, T. (2005). Executive function in Tourette's syndrome and obsessive-compulsive disorder. Psychological Medicine, 35, 571- 582. [Abstract] 45. Veale, D. (2005). Body Dysmorphic Disorder. In: Encyclopedia of Cognitive Behavioral Therapy (ed A. Freeman) Springer. 44. Veale, D. (2005). Letter: Andy Warhol's self-image. The Times, February 24 http://www.timesonline.co.uk/article/0,,59-1497102,00.html 43. Veale, D. and Willson, R. (2005). Overcoming Obsessive Compulsive Disorder. Robinson publishing, London. [Purchase from Amazon] 42. Veale, D. (2005). Chapman, H. Letter: Classification approach for phantom bite. British Dental Journal, 198, 2-3. [Download] 41. Veale, D. (2004). E-letter: Underestimation of Body Dysmorphic Disorder in the community. British Journal of Psychiatry (5 October 2004) http://bjp.rcpsych.org/cgi/eletters/184/6/470 40. Veale, D. (2004). Psychopathology of Obsessive Compulsive Disorder. Psychiatry 3, 65-68. [Download] 39. Veale, D. (2004). Body Dysmorphic Disorder. A review. Postgraduate Medical Journal, 80, 67-71. [Abstract] [Download] 38. Veale, D. (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image, 1, 113-125. [Abstract] [Download] 37. Osman, S., Cooper, M., Hackmann, M. and Veale, D. (2004). Spontaneously occurring images and early memories in people with body dysmorphic disorder. Memory, 12, 428 - 436. [Abstract] [Download] 36. Veale, D., De Haro, L. and Lambrou, C. (2003). Cosmetic rhinoplasty in Body Dysmorphic Disorder. British Journal of Plastic Surgery, 56, 546-51.[Abstract] [Download] 35. Veale, D., Kinderman, P., Riley, S. and Lambrou, C. (2003). Self-discrepancy theory in body dysmorphic disorder. British Journal of Clinical Psychology, 42, 157-169. [Abstract] [Download] 34. Veale, D. (2003). Treatment of Social Phobia. Advances in Psychiatric Treatment, 9, 258-264. [Abstract] [Download] 33. Veale, D. (2003). He died "peacefully" at home. British Medical Journal, 326, 792. [Download] 32. Veale, D. (2003). Obsessive Compulsive Spectrum Disorders. In: Obsessive Compulsive Disorder. Menzies, J. & De Silva P. (Eds.) Wiley: Chichester. [Purchase from Amazon to come] 31. Veale, D. and Lambrou, C. (2002) The importance of aesthetics in Body Dysmorphic Disorder. CNS Spectrums, 7, 429-431. [Abstract] 30. Veale, D., Ennis, M. and Lambrou, C. (2002). Body Dysmorphic Disorder is associated with an occupation or education in art and design. American Journal of Psychiatry, 159, 1788-1790. [Abstract] [Download] 29. Veale, D. (2002). Body Shame in Body Dysmorphic Disorder. In: Body Shame. Gilbert, P. (Ed.) John Wiley: Chichester.[Purchase from Amazon] 28. Veale, D. (2002). Cognitive Behaviour Therapy for Body Dysmorphic Disorder. In: Disorders of Body Image. Castle, D. & Phillips, K. (Editors). Wrightson Biomedical Publishing: Petersfield, UK. [Purchase from Amazon to come] 27. Veale, D. (2002). Over-valued ideas: a conceptual analysis. Behaviour Research & Therapy, 40, 383-400. [Abstract] [Download] 26. Veale, D. and Riley, S. (2001). Mirror, mirror on the wall, who is the ugliest of them all? The psychopathology of mirror gazing in body dysmorphic disorder. Behaviour Research and Therapy, 39, 1381-1393. [Abstract] [Download] 25. Veale, D. Section on pharmacological treatment of anxiety disorders. The Bethlem & Maudsley NHS Trust Prescribing Guidelines 6th edition. 24. Veale, D. (2001). Cognitive Behaviour Therapy for Body Dysmorphic Disorder. Advances in Psychiatric Treatment, 7, 125-132. [Download] 23. Veale, D. (2000). Outcome of cosmetic surgery and 'DIY' surgery in patients with Body Dysmorphic Disorder. Psychiatric Bulletin, 24, 218-221 [Abstract] [Download] 22. Veale, D. (2000). Invited comment: "Everybody looks at my pubic bone" - a case report of an adolescent patient with body dysmorphic disorder. Acta Psychiatrica Scandinavica, 101, 80-82. [Download] 21. Riley, S. and Veale, D. (1999). The Internet and its relevance to Behavioural and Cognitive psychotherapists. Behavioural and Cognitive Psychotherapy, 27, 37-46. [Abstract] 20. Veale, D. (1999). Cognitive therapy in the treatment of Obsessive Compulsive Disorder. Advances in Psychiatric Treatment, 5, 61-70. 19. Ogden, J., Veale, D. and Summers, Z. (1997). Development and validation of the exercise dependence questionnaire. Addiction Research, 5, 343-356.[Abstract] 18. Nezirogulu, F., Hoffman, J., Yaryura-Tobias, J., Veale, D. and Cottraux, J. (1996). Current issues in Behavior and Cognitive Therapy for Obsessive Compulsive Disorder. CNS Spectrums, 1, 47-54. 17. Veale, D., Sahakian, B., Owen, A. and Marks I. (1996). Cognitive deficits in Obsessive Compulsive Disorder. Psychological Medicine, 26, 1261-1269. [Abstract] 16. Veale, D., Gournay, K., Dryden, W. and Boocock, A. (1996). Body Dysmorphic Disorder: a cognitive behavioural model and a pilot randomised controlled trial. Behaviour, Research and Therapy, 34, 717-729. [Abstract] [Download] 15. Veale, D., Boocock, A., Gournay, K. and Dryden, W. (1996). Body Dysmorphic disorder: a survey of 50 cases. British Journal of Psychiatry, 169, 196-201 [Abstract] 14. Veale, D. (1995). Does Primary Exercise Dependence really exist? In: Exercise Addiction: Motivation for participation in sport and exercise. Annett J, Cripps B, & Steinberg, H. (Editors) British Psychological Society, Sport and Exercise Psychology Section, p1-5. 13. Veale, D. (1995). Friday 13th and obsessive-compulsive disorder: Editorial. British Medical Journal, 311, 963-964. [Article] 12. Veale, D. (1994). What is good practice in supervision for behavioural and cognitive psychotherapists? Behavioural Cognitive Bulletin, Royal College of Psychiatrists, 2, 9-10. 11. Veale, D. (1993). Classification and treatment of obsessional slowness. British Journal of Psychiatry, 162, 198-203. [Abstract] 10. Veale, D., Le Fevre, K., Pantelis, C., De Souza, V., Mann, A. and Sargeant, A. (1992). Aerobic exercise in the adjunctive treatment of depression: a randomised controlled trial. Journal of the Royal Society of Medicine, 85, 541-544. [Abstract] 9. Veale, D. (1992). Cognitive behaviour therapy in depression. Depression Briefing, 3, 20-23. 8. Veale, D. (1991). Psychological aspects of staleness and exercise dependence. International Journal of Sports Medicine, 12, S19-S22. [Abstract] 7. Veale, D. (1990). Training and appointment of consultants in Behavioural Psychotherapy. Psychiatric Bulletin, 14, 217-219. [Abstract] 6. Veale, D. (1990). Management of Obsessive Compulsive Disorder. British Journal of Hospital Medicine, 43, 278-281. 5. Veale, D. (1988). Reply to letter on exercise dependence. British Journal of Addiction, 83, 447. 4. Veale, D. (1987). Exercise Dependence. British Journal of Addiction, 82, 735-740. [Abstract] 3. Veale, D. (1987). Letter: Beta-endorphin - a factor in "fun run" collapse? British Medical Journal, 294, 1415-1416. 2. Veale, D. (1987). Exercise and Mental Health. Acta Psychiatrica Scandinavica, 76, 113-120. [Abstract] 1. Veale, D. (1985). Letter: Aerobic exercise in the treatment of depression. British Medical Journal, 291, 487. Abstracts [Top] 55. Deafness Identity: an extreme form of avoidance [Return] Abstract: A case is described of patient who had a compelling and persistent desire to become deaf. She experienced hyperacusis and misophonia. She often lived as a deaf person with cotton wool moistened with oil in her ears and was learning British sign language. Living without sound was a severe form of avoidance behaviour that intensified her hyperacusis but she felt unwilling to participate in a programme of systematic exposure for treating hyperacusis or misophonia. She had a borderline personality disorder which was associated with a poor sense of self. Her desire to be deaf was therefore one aspect of gaining an identity and to compensate for feeling like an alien and her values of isolation, few responsibilities, and acceptance in the deaf community. 54. The psychopathology of vomit phobia [Return] Abstract : A survey of individuals was conducted on self-diagnosed vomit phobics compared to panic disorder and non-clinical controls. Vomit phobics were overwhelmingly female and had had symptoms for over 25 years. They were significantly more likely to fear themselves vomiting (in public and private situations) than fear others vomiting. The vomit phobics interpreted sensations of nausea as impending vomit and had a wide range of safety seeking and avoidance behaviours that were maintaining their fear. Although the vomit phobics reported feeling nauseous more often, there was no difference in their frequency of vomiting compared to the control group. The clinical implications of the study for therapy are discussed. Executive function in Tourette's syndrome and obsessive-compulsive disorder [Return] Background. Cognitive performance was compared in the genetically and neurobiologically related disorders of Tourette’s Syndrome (TS) and obsessive-compulsive disorder (OCD), in three domains of executive function: planning, decision-making and inhibitory response control. Method. Twenty TS patients, twenty OCD patients and a group of age-and IQ-matched normal controls completed psychometric and computerized cognitive tests and psychiatric rating scales. The cognitive tests were well-characterized in terms of their sensitivity to other fronto-striatal disorders, and included pattern and spatial recognition memory, attentional set-shifting, and a Go/No-go set shifting task, planning and decision-making. Results. Compared to controls, OCD patients showed selective deficits in pattern recognition memory and slower responding in both pattern and spatial recognition, impaired extra-dimensional shifting on the set-shifting test and impaired reversal of response set on the Go/No-go test. In contrast, TS patients were impaired in spatial recognition memory, extra-dimensional set-shifting, and decision-making. Neither group was impaired in planning. Direct comparisons between the TS and OCD groups revealed significantly different greater deficits for recognition memory latency and Go/No-go reversal for the OCD group, and quality of decision-making for the TS group. Conclusions. TS and OCD show both differences (recognition memory,
decision-making) and similarities (set-shifting) in selective profiles
of cognitive function. Specific set-shifting deficits in the OCD group
contrasted with their intact performance on other tests of executive
function, such as planning and decision-making, and suggested only
limited involvement of frontal lobe dysfunction, possibly consistent
with OCD symptomatology. 39. Body Dysmorphic Disorder: A review [Return] Abstract: Body dysmorphic disorder (BDD) is defined as a preoccupation with an ‘‘imagined’’ defect in one’s appearance. Alternatively, where there is a slight physical anomaly, then the person’s concern is markedly excessive. The preoccupation is associated with many time consuming rituals such as mirror gazing or constant comparing. BDD patients have a distorted body image, which may be associated with bullying or abuse during childhood or adolescence. Such patients have a poor quality of life, are socially isolated, depressed, and at high risk of committing suicide. They often have needless dermatological treatment and cosmetic surgery. The condition is easily trivialised and stigmatised. There is evidence for the benefit of cognitive behaviour therapy and selective serotonin reuptake inhibitors in high doses for at least 12 weeks, as in the treatment of obsessive-compulsive disorder. There is no evidence of any benefit of antipsychotic drugs or other forms of psychotherapy. 38. Advances in a cognitive behavioural model of body dysmorphic disorder [Return] Abstract: Body dysmorphic disorder (BDD) is the most distressing and handicapping of all the body image disorders. A cognitive behavioural model of BDD is discussed which incorporates evidence from recent studies and advances in the author’s 1996 conceptual model. The model aims to understand the maintenance of symptoms in BDD, to assist in the process of engagement of therapy and to guide the strategies to use. At the core of BDD is an excessive self-focussed attention on a distorted body image, the negative appraisal of such images leading to rumination, changes in mood and the use of safety behaviours. Evidence for possible risk factors in the development of BDD is also discussed. 37. Spontaneously occurring images and early memories in people with body dysmorphic disorder [Return] Abstract: The current study aimed: (1) to investigate the presence and phenomenological characteristics of spontaneously occurring (appearance-related) images/impressions in BDD patients, (2) to identify any negative core beliefs associated with these images, and (3) to investigate links with early memories/experiences. Eighteen patients with BDD and 18 normal controls took part. A semi-structured interview assessing the presence and characteristics of spontaneous appearance-related images/impressions was designed and administered. The BDD patients were found to have spontaneously occurring appearance-related images/impressions that were significantly more negative, recurrent, and viewed from an observer perspective than control participants. These images/impressions were also more vivid and detailed and typically involved visual and organic sensations. They were perceived to be at least partially distorted, but significantly less so than the images/impressions of control participants. Negative core beliefs, particularly related to the self, were accessed via BDD images/impressions and analysis revealed that they were also linked to early stressful memories. Implications for theory and clinical practice are discussed. 36. Cosmetic rhinoplasty in of body dysmorphic disorder [Return] Abstract: Body dysmorphic disorder (BDD) occurs in about 5% of patients seeking cosmetic surgery. Such patients are often dissatisfied with surgery or their symptoms of BDD are the same or worse after surgery. We report on a study that was designed to determine the frequency of BDD in patients requesting cosmetic rhinoplasty in the UK and to compare them with BDD patients in a psychiatric clinic. In the first stage of the study, we used a screening questionnaire for BDD and found that 20.7% of patients requesting rhinoplasty had a possible diagnosis of BDD. However, we believe that we identified a group of patients with sub-clinical or very mild BDD who are satisfied by cosmetic rhinoplasty. In the second stage of the study, we compared (a) patients without BDD who had a good outcome after cosmetic rhinoplasty with (b) BDD patients seen in a psychiatric clinic (who crave cosmetic rhinoplasty but for a variety of reasons do not obtain it). We found that BDD patients seen in a psychiatric clinic who desire cosmetic rhinoplasty are a quite distinct population from those obtaining routine rhinoplasty without symptoms of BDD. BDD patients are significantly younger, more depressed and anxious than this group, and are more preoccupied by their nose and check their nose more frequently. They are more likely to conduct ‘D.I.Y’ surgery and have multiple concerns about their body. They are more likely to be significantly handicapped in their occupation, social life, and in intimate relationships and to avoid social situations because of their nose. They are therefore more likely to believe that dramatic changes would occur in their life after a rhinoplasty. This study provides some clues for surgeons who wish to identify patients with BDD who might have a poor prognosis in cosmetic rhinoplasty. Further research is required in the development of a screening questionnaire or interview for identifying patients with BDD seeking cosmetic surgery. 35. Self-discrepancy in body dysmorphic disorder [Return] Abstract: Objectives: According to self-discrepancy theory, depression, social anxiety, eating disorders and paranoia result from different types of conflicting self-beliefs. Body Dysmorphic Disorder (BDD) consists of a preoccupation with imagined or slight defects in one's appearance, which is often associated with a depressed mood and social anxiety. Self-discrepancy theory was therefore applied to BDD patients to further understand their beliefs about their appearance. Design: Using a comparative group design, BDD patients were compared against a non-patient control group. Methods: 149 participants, consisting of 3 groups; BDD (72); BDD (preoccupied with their weight & shape) (35); and controls (42) completed a modified version of the Selves questionnaire (Higgins et al, 1986) requiring them to list and rate physical characteristics according to the following standpoints: (a) self-actual; (b) self-ideal; (c) self-should; (d) other-actual; (e) other-ideal. Results: BDD patients displayed significant discrepancies between their self-actual and both their self-ideal and self-should. There were no significant discrepancies in BDD patients however, between their self-actual and other-actual or other-ideal domains. Conclusions: The results suggest that BDD patients have an unrealistic ideal or demand as to how they should look. BDD patients are more like depressed patients (rather than than social phobics or bulimics) being more concerned with a failure to achieve their own aesthetic standard than with a perceived ideals of others. 34. Treatment of social phobia [Return] Abstract: Social phobia (or social anxiety disorder) manifests as a marked and persistent fear of negative evaluation in social or performance situations.The epidemiology, diagnosis and psychopathology are reviewed, including clinical presentation, cultural aspects and the differences between agoraphobia and social phobia. Behavioural treatments, including graded self-exposure and cognitive restructuring, are considered. A cognitive model of the maintenance of social phobia is discussed. It is hypothesised that attentional shifting towards imagery, safety behaviours and ‘post-mortem’ analyses play a key role in symptom maintenance. The implications of this for treatment are described, and guidelines for pharmacological treatment are summarised. 31.The importance of aesthetics in BDD [Return] Abstract: The role of aesthetics in the development and maintenance of BDD is explored. It is hypothesised that BDD patients are firstly more "aesthetical" (an attribute like being musical, which varies in different individuals). This results in a greater emotional response to more attractive individuals and placing greater value on the importance of appearance in their identity compared to healthy individuals. Some BDD patients may have greater aesthetic perceptual skills and this is manifested in their education or training in art and design. Secondly BDD patients may have higher aesthetic standards than the rest of the population. Their failure to achieve an unrealistic aesthetic aesthetic standard is at the core of BDD leading to the severe and distress and handicap. 30. Body Dysmorphic Disorder is associated with an occupation or education in art or design [Return] Abstract: Objective: We hypothesised that because Body Dysmorphic Disorder (BDD) patients are preoccupied with aesthetics and their appearance, they were more likely to have an occupation or education in art and design than comparative groups of psychiatric patients. Method: The occupation and higher education or training was extracted from the case notes of 100 consecutive patients with BDD and compared to 100 consecutive patients with a Major Depressive Episode, 100 with Obsessive Compulsive Disorder (OCD) and 100 with Post Traumatic Stress Disorder (PTSD). Results: 20% of the BDD patients had an occupation or education in art or design compared to 4% in the depressed group, 3% in the OCD group and 0% in the PTSD group. Conclusions: The onset of BDD is usually gradual during adolescence and an education in art and design may be a contributory factor to its development in some patients. An equally plausible explanation is that BDD patients have a selection bias for an interest in aesthetics. 27. Overvalued ideas: a conceptual analysis [Return] Abstract: Overvalued ideas are truly a neglected area of psychopathology with few experimental studies published. There is a different emphasis in the USA and Europe as to their definition. For authors in the USA an overvalued idea has become shorthand for 'poor insight' in a middle of a continuum of obsessional doubts to delusional certainty. Compared to negative thoughts, obsessions and delusions, they are often more resistant to any treatment. A better understanding of overvalued ideas is required if advances are to be made in therapy and in the development of appropriate measures to evaluate the efficacy of novel treatments. A cognitive behavioural model of overvalued ideas is presented which draws upon the philosophical distinction between beliefs and values. It is argued that overvalued ideas are associated with idealised values, which have developed into such an over-riding importance, that they totally define the 'self' or identity of the individual. Idealised values are also characterised by the rigidity with which they are held. Such patients are unable to adapt to different circumstances and ignore the consequences of acting on their value. This analysis leads to a discussion of predictions that can be tested and various strategies that can be used in cognitive behaviour therapy.
26. Mirror, mirror on the wall, who is the ugliest them of all? [Return] Abstract: Patients with Body Dysmorphic Disorder (BDD) may spend more hours in front of a mirror but little is known about the psychopathology or the factors that maintain the behaviour. A self-report mirror gazing questionaire was used to elicit beliefs and behaviours in front of a mirror. Two groups were compared, which consisted of 55 controls and 52 BDD patients. Results: Prior to gazing, BDD patients are driven by the hope that they will look different; the desire to know exactly how they look; a belief that they will feel worse if they resist gazing and the desire to camouflage themselves. They were more likely to focus their attention on an internal impression or feeling (rather than their external reflection in the mirrror) and on specific parts of their appearance. They were also more likely to practice showing the best face to pull in public or to use 'mental cosmetic surgery' to change their body image than controls. BDD patients invariably felt worse after mirror gazing and were more likely to use ambiguous surfaces such as the backs of CDs or cutlery for a reflection. Conclusion: Mirror gazing in BDD consists of a series of complex safety behaviours. It does not follow a simple model of anxiety reduction that occurs in the compulsive checking of obsessive-coimpulsive disorder. The implications for treatment are discussed. 23. Outcome of cosmetic surgery and 'D.I.Y' surgery in patients with Body Dysmorphic Disorder [Return] Abstract: Aims and Method: Little is known about the outcome of cosmetic surgery in patients with body dysmorphic disorder (BDD). Self-reported outcome was collected on 25 patients with BDD who at the same time of psychiatric assessment had reported that they had had cosmetic surgery in the past. Results: Twenty-five patients with BDD had a total of 46 procedures. The worst outcome was found in those who had had rhinoplasty and those with repeated operations. Mammoplasty and pinnaplasty was associated with higher degrees of satisfaction. Nine patients with BDD, either in desperation at being turned down for cosmetic surgery or because they could not afford it, had performed their own 'DYI' surgery in which they attempted by their own hand to alter their appearance dramatically. Clinical Implications: Cosmetic surgery cannot at present be recommended for patients with BDD. However, patients turned down for surgery who cannot afford it, may try to alter their appearance by themselves. The study contains a selection bias of patients in favour of treatment failures in cosmetic surgery and prospective studies are required on BDD patients who obtain cosmetic surgery or dermatological treatment. 21. The Internet and its relevance to Behavioural and Cognitive psychotherapists [Return] Abstract: The potential uses of the Internet to behavioural and cognitive psychotherapists and researchers are manifold. This article summarizes what the Internet is, how to connect to it, searching the Web, on-line publishing, discussion forums, chat rooms, literature searching, transfer of documents and creating a web-site. It considers the potential of the Internet technology in therapy and enhancing patient/therapist contact. A web page containing links to many of the sites referred to in this article as well as additional links and resources is accessible through the BABCP website (www.babcp.org.uk). 19. Development and validation of the exercise dependence questionnaire [Return] Abstract: The aim of the present study was to develop and validate the Exercise Dependence Questionnaire (EDQ). 86 statements, derived from semi structured questionnaires, were used to develop a self report rating scale which was completed by 449 subjects who exercised for more than 4 hours a week. Factor analysis was used and items not loading onto any factors. 17. Cognitive deficits in Obsessive Compulsive Disorder [Return] Abstract: Forty patients with obsessive compulsive disorder (OCD) were compared to matched healthy controls on neuropsychological tests which are sensitive to frontal lobe dysfunction. On a computerised version of the Tower of London test of planning, the patients were no different from healthy controls in the accuracy of their solutions. There was no difference between the groups in the time spent thinking prior to making the first move or in the time spent thinking after the first move when "perfect move" solutions were considered. However, when the patients made a mistake, they spent more time than the controls generating alternative solutions or checking that the next move would be correct. The results suggest that OCD patients have a selective deficit in generating alternative strategies when they make a mistake. In a separate attentional set-shifting task, OCD patients were impaired in a simple discrimination learning task and showed a continuous cumulative increase in the number who failed at each stage of the task, including the crucial extra- dimensional set shifting stage. This suggests that OCD patients show deficits in both acquiring and maintaining cognitive sets. The cognitive deficits in OCD may be summarised as a problem of (i) being easily distracted by other competing stimuli, (ii) excessive monitoring and checking of the response to ensure a mistake does not occur, (iii) when a mistake does occur, being more rigid at setting aside the main goal and planning the necessary sub-goals. Both studies support the evidence of fronto-striatal dysfunction in OCD and the results are discussed in terms of an impaired Supervisory Attentional System (Norman and Shallice, 1980). 16. Body Dysmorphic Disorder: a cognitive behaviour model and a pilot randomised controlled trial [Return] Abstract: A cognitive behavioural model of body image is presented with specific reference to body dysmorphic disorder (BDD). We make specific hypotheses from the model for testing BDD patients in comparison to (i) patients with "real" disfigurements who seek cosmetic surgery, (ii) subjects with "real" disfigurements who are emotionally well adjusted and (iii) healthy controls without any defect. There have been no randomised controlled trials of treatment for BDD and therefore the model has clear implications for the development of cognitive behavioural therapy. This was evaluated in a pilot controlled trial. Nineteen patients were randomly allocated to either cognitive behaviour therapy or a waiting list control group over 12 weeks. There were no significant pre-post differences on any of the measures in the waiting list group. There were significant changes in the treated group on specific measures of Body Dysmorphic Disorder and depressed mood. Cognitive behaviour therapy should be further evaluated in a larger controlled trial in comparison to another psychological treatment such as interpersonal therapy and pharmacotherapy. 15. Body dysmorphic disorder: a survey of 50 cases [Return] Abstract: Background: Body Dysmorphic Disorder (BDD) consists of a preoccupation with an "imagined" defect in appearance which causes significant distress or impairment in functioning. There has been little previous research into BDD. This study replicates a survey from the USA in a UK population and evaluates specific measures of BDD. Method: Cross-sectional interview survey of 50 patients who satisfied DSMIV criteria for BDD as their primary disorder. Results: The average age at onset was late adolescence and a large proportion of patients were either single or divorced. Three quarters of the sample were female. There was a high degree of co-morbidity with the most common additional Axis 1 diagnoses being either a mood disorder(26%), social phobia(16%) or obsessive compulsive disorder(6%). 24% had made a suicide attempt in the past. Personality disorders were present in 72% of patients, the most common being paranoid, avoidant and obsessive compulsive. Conclusions: BDD patients had a high associated comorbidity and previous suicide attempts. BDD is a chronic handicapping disorder and patients are not being adequately identified or treated by health professionals. An increased awareness of BDD and its associated morbidity is required. 13. Friday 13th and obsessive compulsive disorder [Return] Article: Most readers of this journal are probably not superstitious. They are unlikely to change their behaviour this Friday the 13th despite a study showing significantly more road traffic accidents on Friday the 13th than Friday the 6th. They might, however, "touch wood" or choose a lucky number in the national lottery. People who are superstitious take it further. They see a causal relation between their own thoughts or actions and events in the world. Superstitions flourish whenever people cannot tolerate uncertainty or believe that they have no control over events; they lead us to believe that we can influence outcomes. Superstitiousness correlates significantly with the obsessional thoughts and compulsive checking experienced by people with obsessive compulsive disorder. Obsessive compulsive disorder consists of obsessions or compulsions or, most commonly, the two combined. Obsessions are recurrent intrusive thoughts, images, or urges that cause considerable anxiety or disgust. Typical obsessions concern contamination, misfortune, violence, blasphemy, and sex. Compulsions are thoughts or actions that a person feels driven to repeat. They include ritualistic cleaning, checking, counting or touching of objects, hoarding, and superstitious behaviour. According to one cognitive model, people with obsessive compulsive disorder experience fusion of their thoughts and actions. Having a bad thought (about, for example, abusing a child) becomes morally equivalent to doing the act itself, while failing to prevent a bad event becomes equivalent to being responsible for the harm inflicted. A recent epidemiological survey in the United States found that obsessive compulsive disorder was the fourth most common psychiatric disorder in the community but that many sufferers did not seek help or took up to 10 years before consulting a health professional. Sufferers typically try to suppress intrusive thoughts. They may also try to neutralize them by using mental rituals such as counting to 10 or reciting simple rhymes to themselves. These attempts to suppress or neutralize intrusive thoughts can, however, make matters worse, since they tend to reinforce the obsessive compulsive behaviour pattern. Our understanding of the biological correlates of obsessive compulsive disorder has progressed, allowing us to integrate biological and psychological models. Of particular interest have been reports suggesting that people with the disorder have smaller caudate nuclei than healthy controls, leading to inadequate filtering of outputs from the orbitofrontal region of the brain. [Return] The main options for management are behaviour therapy, cognitive therapy, and treatment with drugs. In behaviour therapy the patients are helped to face the situations that they have been avoiding and to resist ritualistic responses to their compulsions. About a quarter of patients, however, either decline such treatment or drop out once it has started. Of those who participate, about three quarters respond well. Some patients may benefit from establishing their own programme of behaviour therapy with the help of lay volunteers. Cognitive therapy entails teaching patients to recognize obsessions simply as thoughts. Patients are encouraged to make realistic estimates of the likelihood of a bad event actually happening and of the degree of their responsibility for it if it did happen. A recent trial suggests that cognitive and behavioural therapy are equally effective, and there is growing interest in integrating the two. For those who decline behavioural and cognitive therapy or who do not respond fully, the treatment of choice is antiobsessional drugs, either potent or selective serotonin reuptake inhibitors. About 60% of patients will respond, with on average a halving of symptoms even in the absence of depression. Patients may need to be given the highest tolerable dose for up to 12 weeks to achieve the full response. In patients with a comorbid tic disorder the addition of a neuroleptic drug may improve the outcome. Stopping treatment frequently leads to relapse. To reduce the risk of relapse patients should continue treatment long term or be treated with a combination of drugs, behaviour therapy, and cognitive therapy. Selective serotonin reuptake inhibitors have some troublesome side effects, such as anorgasmia. There may be acceptable in the short term treatment of depression but not when treating a chronic condition such as obsessive compulsive disorder. It is not yet known which patients will respond to which treatments or whether there is a hard core of patients who cannot yet be fully treated. For some patients, obsessive compulsive disorder remains a chronic handicap as severe as schizophrenia. 1. Scanlon TJ, Luben RN, Scanlon FX, Singleton N. Is Friday the 13th bad for your health? BMJ 1993;307:1584-6. 2. Frost RO, Krause MS, McHahon MJ, Peppe J, Evans M. Compulsivity and superstitiousness. Behave Res Ther 1993;31:423-5. 3. Salkovskis PM, Richards C, Forrester E. The relationship between obsessional problems and intrusive thoughts. Behavioural and Cognitive Psychotherapy 1995; 23:281-99. 4. Regier DA, Narrow WS, Rae DS, Manderscheid RW, Lock BZ, Goodwin FK, The de facto US mental an addictive disorders service system epidemiological catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry 1993;50:85-94. 5. Tallis F, Obsessive compulsive disorder. A cognitive and neuropsychological perspective. Chichester Wiley, 1995. 6. Robinson D, Wu H, Munne R, Ashtari M, Alvir JM, Lerner G, et al. Reduced caudate nucleus volume in obsessive-compulsive disorder. Arch Gen Psychiatry 1995;52:393-8. 7. Baxter LR, Schwartz JM, Bergman KS, Szuba MP. Caudate glucose metabolic rate changes with both drug and behaviour therapy for obsessive compulsive disorder. Arch Gen Psychiatry 1992;49:681-9. 8. Foa EB, Emmelkamp PMG. Failures in behaviour therapy. New York: Wiley, 1983: 10-34. 9. Van Oppen P, de Haan E, van Balkom AJ, Spinhoven P, Hoogduin K, van Dyck R. Cognitive Res Ther 1995;33: 379-90. 10.Wood A. Pharmacotherapy of OCD. Journal of Serotonin Research 1995;1 (supp 1):63-76 11. McDougle CJ, Goodman WK, Leckman JF, Lee NC, Heninger GR, Price L. Haloperidol addition in fluvoxamine refractory obsessive compulsive disorder. Arch Gen Psychiatry 1994;51:302-8. [Return] 11. Classification and treatment of obsessional slowness [Return] Abstract: Obsessional slowness is regarded as an uncommon but severely disabling variant of obsessive-compulsive disorder. This paper examines the psychopathology, classification, pathophysiology and treatment of obsessional slowness. It argues that primary obsessional slowness does not require classification as a separate syndrome because it can be found to be secondary to recognized phenomena of obsessive-compulsive disorder or anankastic personality disorder. The treatment described in the literature is not thought to be successful in the long term, and controlled trials are required to evaluate new strategies and antidepressant medication. 10. Aerobic exercise in the adjunctive treatment of depression: a randomised controlled trial [Return] Abstract: Two clinical trials have been conducted in a sample of depressed patients to determine whether the addition of an aerobic exercise programme to their usual treatment improved outcome after 12 weeks. In the first trial, an aerobic exercise group had a superior outcome compared with a control group in terms of trait anxiety and a standard psychiatric interview. A second trial was then conducted to compare an aerobic exercise programme with low intensity exercise. Both groups showed improvement but there were no significant differences between the groups. In neither trial was there any correlation between the extent of change in the subjects' physical fitness due to aerobic exercise and the extent of the improvement of psychiatric scores. 8. Psychological aspects of staleness and exercise dependence [Return] Abstract: This article discusses the psychological symptoms of overtraining and the relationship between staleness and exercise dependence. Staleness may be prevented by monitoring the mood state of the individual so that, if necessary, appropriate action may be taken to taper the volume of training and maximize performance. The criterion for exercise dependence is difficult to define and some suggestions are made on clarifying the diagnosis and future research in this area.
7. Training and appointment of consultants in Behavioural Psychotherapy [Return] Abstract: This article argues for a new initiative in the training and appointment of consultants in behavioural psychotherapy or with a special interest in behavioural psychotherapy. Behavioural psychotherapies are time-limited, directive and problem-orientated. The theoretical models focus on understanding the factors maintaining current problems rather than on their origin. The major emphasis in the therapeutic alliance is not on the bond, but on determining specific and more adaptive goals that the patient wishes to achieve and persuading the patient to carry out specific homework tasks as a means towards achieving these goals. The effects of the tasks are carefully monitored in each individual and the overall efficacy of the strategies used have been evaluated in controlled clinical trials. I include under the rubric of behavioural psychotherapies the cognitive psychotherapies such as rational emotive therapy, cognitive therapy, stress inoculation training, and problem-solving strategies, because they too emphasise goals and tasks and include a significant behavioural component. My own view is that titles such as cognitive-behavioural psychotherapist are too cumbersome and the general trend within the speciality is towards integration of the various approaches and determining which therapeutic strategy is best for which type of patient. 4. Exercise Dependence [Return] Abstract: Exercise can become a compulsive behaviour and harmful to an individual. This review proposes diagnostic criteria for "exercise dependence" to facilitate recognition in Sports clinics and further research. The importance of diagnosing exercise dependence lies in the prevention of morbidity and rarely mortality if exercise is continued in the presence of illness or injury. There is insufficient evidence to postulate opioid peptides as a physiological basis of dependence. A distinction is made between a primary form of exercise dependence and that which is secondary to an eating disorder. 2. Exercise and Mental Health [Return] Abstract: This paper reviews the mood altering properties of exercise and its potential in the prevention and treatment of mental disorders. The role of the brain monoamines, opioid peptides, the sympathetic nervous system, and cognitive behavioural theory as mediating pathways for the psychological benefits of exercise is critically examined. Clinical trials on exercise are reviewed and suggestions are made for future research in this field. return to the top
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