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  1. Body dysmorphic disorder: recognizing and treating imagined ugliness
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  3. Shutter Island's ending explained | David Cox | Film | The Guardian

The film's been described as faithful to the book , and many cinemagoers seem to have assumed that it's telling the same story. Leonardo DiCaprio's Teddy does indeed turn out to be Andrew. However, before he falls into the clutches of the lobotomists, he utters a line that isn't in the book. For some, this is to be seen as no more than the rambling of a madman.

Others, however, take it as meaning that Andrew's only faking his relapse. His unusual treatment's made him aware of the terrible thing he's done: These two versions of what the film means could hardly be more at odds. Yet Scorsese hasn't chosen to indicate which is the right one. Perhaps the latter isn't sure himself. He found his role traumatising , and told an interviewer: Lehane is credited as one of the film's executive producers, so you might think he at least would know what's going on. Sadly, even he doesn't seem wholly certain: When pushed, he tries to reconcile DiCaprio's gnomic inquiry with his own original story.

It's just one moment of sanity mixed in the midst of all the other delusions.

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Body dysmorphic disorder: recognizing and treating imagined ugliness

As it happens, just how to end the film was much debated by those more directly involved. On a visit to the location where most of the film was shot, the now-abandoned Medfield state hospital in Massachusetts, I asked the professor what was really supposed to be happening. His answer was clear cut. Andrew does indeed choose his fate. According to Gilligan, those cryptic last words mean: I'm not going to actually commit suicide, but I'm going to vicariously commit suicide by handing myself over to these people who're going to lobotomise me.

If treatment returns them to their senses, guilt may then overwhelm them.

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For Gilligan, the correct reading is important. Shutter Island is set in the s. During that era, severe mental disturbances were often dealt with physically. In America, more than 40, patients were lobotomised over a year period. However, progressives were pushing for the replacement of such methods by less ruinous remedies. Andrew's doctor played by Ben Kingsley is one of these.

His role-play experiment is a test case. In an open series of 13 patients treated with group CBT, BDD significantly improved in twelve minute group sessions In a study of 10 participants who received thirty minute individual ERP sessions without a cognitive component, plus 6 months of relapse prevention, improvement was maintained at up to 2 years Two wait-list controlled studies have been published. In a randomized pilot study of 19 patients, those who received 12 weekly sessions of minute individual CBT improved significantly more than those in a no-treatment wait-list control condition The above findings are very promising, but more rigorously controlled studies are needed.

Also requiring investigation are the optimal number, duration, and frequency of sessions as well as the relative efficacy of group versus individual treatment. It is not known whether behavioral treatment ERP alone is usually effective or whether cognitive restructuring and behavioral experiments are a necessary treatment component because of the poor insight and depression so often characteristic of BDD.

A broadly applicable treatment manual is not available and is needed. It is also not known whether SRIs or CBT is more effective, or whether their combination is more effective than either treatment alone. Many patients appreciate referrals to books or websites e. For patients who are reluctant to accept the diagnosis and treatment e.

Research on insight-oriented and supportive psychotherapy is extremely limited but suggests that BDD symptoms - especially severe symptoms - are unlikely to significantly improve with these treatments alone 2. A majority of patients with BDD seek and receive surgery or nonpsychiatric medical e. Some, in desperation, even do their own surgery - for example, attempting a facelift with a staple gun or trying to replace their nose cartilage with chicken cartilage in the desired shape 9 , Although prospective studies are lacking, such treatments appear to usually be ineffective.

Systematic treatment outcome studies of patients who clearly have BDD have not been done in nonpsychiatric settings, but observations in the dermatology and surgery literature generally indicate that the outcome of such treatments tends to be poor 53 , Occasional dissatisfied patients commit suicide or are violent toward the treating physician 1. BDD is a severe and relatively common psychiatric disorder that occurs around the world.

However, it usually goes undiagnosed in clinical settings. It is important to diagnose BDD, as it causes significant impairment in functioning and is associated with markedly poor quality of life. However, studies of all aspects of BDD are needed - in particular, treatment studies, epidemiology studies in which BDD symptoms are specifically inquired about and differentiated from other disorders such as hypochondriasis and OCD , cross-cultural studies, and investigation of BDD-related disability and the disorder's cost and burden to society.

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Research is also needed on whether BDD may be more closely related to social phobia, OCD, or depression than to most of the other somatoform disorders with which it is classified. Research on BDD's pathogenesis, including its underlying neurobiology, has just begun; such work may ultimately lead to more effective treatments and prevention of this severe mental disorder.

National Center for Biotechnology Information , U. Journal List World Psychiatry v. Katharine A Phillips 1. Copyright World Psychiatric Association. This article has been cited by other articles in PMC. Abstract Body dysmorphic disorder BDD , also known as dysmorphophobia, is a severe psychiatric disorder that occurs around the world.

Body dysmorphic disorder, dysmorphophobia, delusional disorder, somatoform disorders. Are you very worried about your appearance in any way? Are you unhappy with how you look? Does this concern preoccupy you? That is, do you think about it a lot and wish you could worry about it less? How much time do you spend thinking about fill in body areas of concern? Significantly interfered with your social life, school work, job, other activities, or other aspects of your life? Sulla dismorfofobia e sulla tafefobia: Boll R Accad Genova.

Les obsessions et la psychasthenie. Diagnostic and statistical manual of mental disorders. American Psychiatric Association; A comparison of delusional and nondelusional body dysmorphic disorder in cases. The ICD classification of mental and behavioural disorders.

World Health Organization; Oxford University Press; Revised and expanded edition, in press. Somatoform and factitious disorders. American Psychiatric Publishing; Prevalence, phenomenology, and comorbidity of body dysmorphic disorder dysmorphophobia in a clinical population. Int J Psychiatry Clin Pract. Disorders of body image. Phillips KA, Diaz S. Gender differences in body dysmorphic disorder.

J Nerv Ment Dis. Cognitive-behavioral body image therapy for body dysmorphic disorder. J Consult Clin Psychol. Gender-related differences in body dysmorphic disorder dysmorphophobia J Nerv Ment Dis.


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Gunstad J, Phillips KA. Axis I comorbidity in body dysmorphic disorder. Suicide in dermatological patients. Perceived stress in body dysmorphic disorder.

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Quality of life for patients with body dysmorphic disorder. The syndrome of dysmorphomania dysmorphophobia and the development of psychopathic personality. Muscle dysmorphia in a young Chinese male. Ann Acad Med Singapore. Body dysmorphic disorder in a Ghanaian male: East Afr Med J. Bull Yamaguchi Med School. The man with the purple nostrils: Prevalence of symptoms of body dysmorphic disorder and its correlates: The definition and classification of koro. Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. Prevalence and clinical features of body dysmorphic disorder in atypical major depression.

The high prevalence of "soft" bipolar II features in atypical depression. Zimmerman M, Mattia JI. Body dysmorphic disorder in psychiatric outpatients: Pharmacologic treatment of body dysmorphic disorder: Neziroglu F, Khemiani-Patel S. A review of cognitive and behavioral treatment for body dysmorphic disorder.


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  • Treatment of body-dysmorphic disorder with serotonin reuptake blockers. Fluvoxamine treatment of body dysmorphic disorder. Fluvoxamine in the treatment of body dysmorphic disorder dysmorphophobia Int Clin Psychopharmacol. Efficacy and safety of fluvoxamine in body dysmorphic disorder. Phillips KA, Najar F. An open-label study of citalopram in body dysmorphic disorder. Clomipramine vs desipramine crossover trial in body dysmorphic disorder: A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder.

    Effectiveness of pharmacotherapy for body dysmorphic disorder: Marks I, Mishan J. Dysmorphophobic avoidance with disturbed bodily perception: Cromarty P, Marks I. Does rational role-play enhance the outcome of exposure therapy in dysmorphophobia?

    Shutter Island's ending explained | David Cox | Film | The Guardian

    Effect of cognitive behavior therapy on persons with body dysmorphic disorder and comorbid axis II diagnoses. Cognitive behavior group therapy for body dysmorphic disorder: Two-year follow-up of behavioral treatment and maintenance for body dysmorphic disorder. Outcome of cosmetic surgery and DIY surgery in patients with body dysmorphic disorder.