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Chapter 6

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PSYC 3140
Kendra Thomson

Chapter 6: Somatoform and Dissociative Disorders - Somatoform disorders: proccupation w/ health/appearance dominates one’s life - Soma = body  ppl seem to be concerned w/ physical disorders - What somatoform disorders have in common - No identifiable medical condition causing physical complaints - Dissociative Disorders o Dissociative experiences/dissociation  “detached” from surroundings (“this isn’t really me”) – ppl feel as if they are dreaming  slight alterations/detachments in consciousness or identity  can be intense/extreme that ppl lose entire identity and assume a new one  can lose memory / sense of reality and can’t function - Somatoform and dissociative share common history, common factors o Used to be categorized under heading: hysterical neurosis o Hysteria – Greek Hippocrates, Egyptians – thought that cause of these disorders can be traced to a “wandering uterus” (thought to occur mainly in women) o Hysterical – refers to gen. physical symptoms w/o known organic cause, or to dramatic/histrionic behav in women  Prejudice, stigmatizing o Freud – conversion hysteria – unexplained phys symptoms to explain the conversion of unconscious emotional conflicts - Neurosis (defined by psychoanalytic theory) o Neurotic disorders are caused from underlying unconscious conflicts, anxiety from those conflicts, implementation of ego defense mechanism o “neurosis” eliminated from diagnostic system in 1980 b/c too vague (applied to all non-psychotic disorders), implied specific (but unproven) cause for these disorders SOMATOFORM DISORDERS - DSM IV lists 5 basic somatoform disorder: hypochondriasis, somatization disorder, conversion disorder, pain disorder, body dysmorphic disorder - Inds pathologically concerned w/ appearance / functioning of bodies - Hypochondriasis, somatization disorder, pain disorder  overlap, proposal for DSM 5 is to combine these 3 disorders into new category called complex somatic symptom disorder Hypochondriasis Clinical Description - ancient greeks thought hypochondria was region below ribs, organs in this area affected mental state o eg. ulcers / ab disorders once considered part of hypochondrial symptom - physical complaints w/o clear cause labeled hypochondriasis o severe anxiety focused on possibility of having serious disease o threat seems so real, physicians’ reassurance doesn’t help - hypochondriasis has sim features of anxiety / mood disorders (panic disorder) o sim age of onset, personality characteristics, patterns of fam aggregation (running in fams) o anxiety/mood disorders comorbid w/ hypochondriasis o DSM 5  moving hypochondriasis to anxiety disorder - Hypochondriasis – anxiety/fear that one has serious disease o Anxiety prob, but dif expression than other anxiety disorders o Ind preoccupied w/ bodily symptoms  misinterprets them as illness/disease o Any physical sensation is concerning  normal body functions eg. heart rate/perspiration  small body functions eg. cough  vague symptoms – aches/fatigue o preoccupation w/ physical symptoms – usually seek family physician first  go to mental health profs after doctors rule out medical cause o reassurance from doctors that ind is healthy has short term effect  Cote  inds who fear developing disease (avoid situations associate w/ contagion) are dif from ppl are who anxious us they have a disease  Illness phobia  ppl who have fear of developing disease  Earlier onset  Hypochondriasis  inds who mistakenly believe they currently have disease  More likely to misinterpret phys symptoms, have inc rates of checking behavs, inc anxiety (than ppl w/ illness phobia)  Study: 60% of grp of patients w/ illness phobia developed hypochondriasis and panic disorder - panic disorder and hypochondriasis usually co-occur o Study: approx 50% of patents w/ panic disorder met diagnostic criteria for hypochondriasis, (HC)  HC more common in ppl w/ panic disorder (48%) than patients w/ social phobia (17%) or control (14%) o ppl w/ panic disorder misinterpret physical symptoms as beginning of next panic attack (which believe may kill them) o Differences  Panic disorder – fear immediate symptom related catastrophes that occur few mins before panic attack  HC – focus on long term process of illness / disease (eg. cancer/AIDS)  Anxieties of panic disorder focus on 10-15 sympathetic nervous system symptoms associated w/ panic attack (HC has wider range of concerns) Statistics - 1-14% of med patients diagnosed w/ HC - Study: 1400 patients in primary care settings – 3% met criteria for HC - 50-50 sex ratio (although used to be considered a “hysterical” disorder unique to women) - used to think that HC more prev in elderly (not true) - HC spread evenly across adulthood o Little bit higher in elderly - HC can come at any age in life  peak periods in adolescence, mid age (40s, 50s) and 60+ - Chronic (same w/ anxiety and mood disorders) - Study -100+ patients w/ HC and non-HC group followed for 4-5 yrs  2/3 of HC patients still met criteria for diagnosis of HC, and remained sig more symptomatic than comparison group - Culture specific syndromes o Koro – belief that genitals retracting into abdomen  Mainly Chinese males  Anxiety/panic  Few reports in western cultures  Rubin – imp of sexual functioning among Chinese males  ppl who suffer from Koro have excessive masturbation, unsatisfactory intercourse, promiscuity  May predispose men to focus attention on sex organs, inc anxiety/arousal o Dhat – anxious concern about losing semen during sex  Prev in India  Vague symptoms ie. Dizziness, weakness, fatigue  Low-grade depressive/anxious symptoms attributed to semen loss o other culture-bound somatic symptoms associated w/ emotional factors)  in African patients  hot sensations in head, sensation of something crawling on head  Pakistani/Indian patients  sensation of burning in hands/feet - phys symptoms = very challenging o 1. physician rules out physical cause for somatic complaints, refers client to mental health professional o 2. Mental health prof determines nature of somatic complaints (to find out if associated w/ somatoform disorder, or dif psychopathology eg. panic attack) o 3. Clinician needs to be aware of culture/subculture of patient Causes - HC disorder of cognition or perception w/ strong emotions - Inds w/ HC experience common physical sensations (normal) but quickly focus attention on these symptoms (not normal) o Act of focusing on yourself inc arousal, makes phys sensations seem more intense than they really are o Misinterpretation of phys sensations as illness inc anxiety o Inc anxiety produces inc physical symptoms (vicious cycle) - ppl w/ HC and ppl w/ high levels of health anxiety have inc perceptual sensitivity to illness cues (tested w/ Stroop test) o interpret ambiguous stimuli as threatening  become quickly aware (scared) of any sign of possible illness o have restrictive concept of health as being totally “symptom free” - Causes of somatic sensitivity/distorted beliefs o Isolated bio or psychological factors o Causes sim to anxiety disorders  HC runs in fams – but genetic contribution = non specific eg. tendency to over respond to stress  Children w/ HC report same kinds of symptoms as other fam members  Possible that inds w/ HC (like in panic disorder) have learned from fam members to focus anxiety on specific physical sensations  Study: adults w/ inc HC concerns reported more learning experiences in childhood around neg reactions to bodily symptoms than adutls w/ lower levels of HC  Learning experience – eg. being rewarded by parents when child expressed bodily complaint (eg. instrumental learning – being allowed to miss school / inc attention)  Observing parents/fam members expressing anxiety re: bodily sensations (vicarious learning)  Parent/fam member instruct child that all bodily sensations are dangerous/signs of serious illness o Hyperresponsivity can combine w/ tendency to view neg life events as unpredictable/uncontrollable (and need to be guarded against constantly) - 3 other etiological factors o 1. HC develops in context of stressful life event (same w/ anxiety disorders)  eg. death/illness Kristen’s disorder coincided w/ breast cancer of female relative o 2. Ppl w/ HC have disproportionate incidence of disease in family when they were children  even if didn’t develop HC until adulthood, they carry memories of illness tha could become focus of anxiety o 3. Social/interpersonal influence – ppl w/ families where illness is major issue learn that ill person is given inc attention  “benefits” of being sick contribute to later development of HC  “sick person” who receives inc attention, dec responsibility is adopting a “sick role” Treatment - until now – common clinical practice = psychodynamic therapy (little effectiveness) o Study: 4 our of 23 patients had benefit from psychodynamic therapy - CBT effective for HC who are willing to be referred to mental health prof o Exposure to health/illness info that patient is avoiding b/c of health anxiety, learning to challenge illness-related misinterpretations of benign bodily sensations (eg. learning to challenges thoughts that simple rash is sign of cancer) o Study: 83% of patients no longer meet diagnostic criteria of rHC after CBT o Study: randomly assigned 32 patients to either CBT or no-treatment wait-list control group  Treatment focused on identifying/challenging illnesss-related misinterpretations of phys sensations, and showing patients how to create symptoms by focusing attention on certain body areas taught patients that they are in control of bodily sensations  Coached to seek less reassurance from doctors  Treatment group improved 76%, only 5% in wait-list group  Benefits maintained for 3 mos  Ppl w/ CBT retained gains at 1 yr follow up (in another study) - CBT for HC o Adapted Ladouceur’s CBT of GAD for HC  worries about health present n both GAD and HC  Study: using multiple baseline single case design across 6 inds w/ hypochondriasis  demonstrated that using therapy focusing on excessive worry = effective treatment for health anxiety - anti-depressant meds eg. SSRIs (selective serotonin reuptake inhibitors) - Study: CBT therapy most effective treatment (compared to meds) o Fluoxetine (SSRI) is promising med o Psychoeducation sufficient for only mild cases of HC Somatization Disorder (SD) Clinical Description - 1859 – Peirre Briquet (French physician) – patients came to him w/ somatic complaints w/ no medical basis  Somatization disorder (before called Briquet’s syndrome) - concerned w/ symptoms themselves – not afraid of getting a disease (like in HC) o concerned w/ physical symptoms themselves, not w/ what they might mean o HC – take immediate action when notice symptom (by calling doctor/ taking med) o SD – don’t feel urgency to take action, but usually feel weak, ill, avoid exercising (believe exercise will make them worse)  Entire life revolves around symptoms (can claim that symptoms are “identity” of person  don’t know who they are w/o them)  Can only relate to ppl in context of discussing her symptoms - eg. Linda  dropped out of nursing school b/c picked up disease she was learning about in combo w/ stressful emotional events Statistics - rare - DSM III criteria – required 13+ symptoms from list of 35 (dif diagnosis) - Simplified criteria for DSM IV – only 8 symptoms required - SD occurs on continuum o Undifferentiated somatoform disorder  ppl w/ only few medically unexplained phys symptoms, experience distress/impairment of functioning  SD w/ fewer than 8 symptoms  therefore likely to be taken out of DSM V - Study: prev of SD of 4.4% in large city (using 4-6 symptoms as criteria) o Median prev in 6 samples of large # of patients in primary care setting meeting this criteria = 16.6% - adolescence = age of onset - SD patients usually women, unmarried, low SES o 68% of patients in large sample were female - somatic and psychological complaints eg. anxiety / mood disorders - WHO study of inds in primary care settings w/ SD or insufficient somatic complaints to meet criteria for disorder  uniform rates around the world for somatic complaints and sex ration of SD Causes - sim features w/ HC – history of family illness/injury during childhood (minor factor – many fams experience chronic illness/injury w/o passing on sick role to children) - ppl w/ SD more sensitive to physical sensations / overattend to them - past difficulty of making diagnosis – few etiological studies have been done - mixed results for genetic contribution o Twin Study: no inc prev of SD in monozygotic pairs o SD runs in families, may have heritable basis o SD strongly linked in family/genetic studies to antisocial personality disorder (ASPD)  characterized by vandalism, persistent lying, theft, irresponsibility w/ finances/work, physical aggression , insensitive to punishment and neg consequences of impulsive behav, little anxiety/guilt  ASPD mainly in males, SD mainly in females  Both begin early in life, chronic, mainly in low SES, difficult to treat  Both associated w/ marital discord, drug/alc abuse, suicide attempts  Family/adoption studies  ASPD and SD run in fams, may have heritable component and that behavs can be learned in maladaptive family settings - Integration of biopsychosocial factors of ASPD and SD o 1. Both share neurobiologically based disinhibition syndrome characterized by impulsive behav  impulsiveness common in ASPD  SD – behaviours have short-term gain, long-term probs  development of new somatic symptoms gains immediate sympathy but eventually leads to social isolation  Same neurophysiological vulnerability  but then why do both disorders behave so differently?  Strong effect of social / cultural factors  Major dif b/w disorders is degree of dependence  Gender roles  strong component of identity o **Gender socialization accounts for major dif in expression of same biological vulnerability in men and women (eg. aggression strongly associated w/ males in mammals) - Canadian Psychological Association – always unethical to have any sexual contact w/ patient at any time during treatment Treatment - SD dif to treat, no treatments exist to cure syndrome - Ppl w/ SD are resistant to having a psychological cause applied to their physical symptoms  resistance makes them avoid / likely to discontinue psych treatment - Treatment can include reassurance, reducing stress, reducing frequency of help-seeking behavs - Common patterns = person’s tendency to visit many medical specialists according to ‘symptom of the week’ - To limit visits – gatekeeper physician assigned to each patient to screen all physical complaints o Subsequent visits to specialist have to be authorized by gatekeeper - treatment focuses on reducing using physical symptoms as a way to relate to others (encouraged to interact w/ others in more appropriate ways) - randomized controlled studies - written consultation letters sent to physicians to educate them about SD are effective to dec excessive help- seeking behav in ppl w/ SD o this intervention doesn’t improve psychological distress of patient - group CBT therapy has additional benefit in dec health care costs, and improves SD patients’ psychological well-being CONVERSION DISORDER - conversion –Freud believed that anxiety results form unconscious conflicts that are “converted” into physical symptoms to find expression o the “conversion” allowed ppl to release anxiety w/o experiencing it o eg. phobic disorders – anxiety resulting from unconscious conflicts are “displaced” onto another object Clinical Description - Conversion disorders deal w/ physical malfunctioning eg. paralysis, blindness, difficulty speaking (aphonia) w/o any physical or organic pathology to account for malfunction, loss of sense of touch o some ppl have seizures – may have psychological origin b/c no EEG changes can be documented o blobus hystericus – sensation of lump in throat that makes it dif to swallow, eat, talk - Conversion symptoms mimics full range of physical malfunctioning - Proposal to change name to “functional neurological disorder” (“functional”  symptom w/o organic cause) o Eg. someone going blind when visual processes are normal, have arm/leg paralysis w/o neurological damage - Astasia-Abasia – weakness in legs, difficulty keeping balance, frequent falling Closely Related Disorders - conversion reactions have indifference to symptoms (same as SD)  attitude called la belle indifference - conversion symptoms often precipitated by marked stress o marked stress before conversion symptom occurred in 52-93% of patients  stress in form of physical injury  Study: 324 out of 869 patients (37%) reported prior physical injury  If clinician can’t identify stressful event before onset of conversion symptom, inc chance of real physical condition - Can function normally – unaware of this - Eg. inds /w/ conversion symptom of blindness can avoid objects in visual field, but will tell you they can’t see the objects - Eg. conversion symptom paralysis – might be able to run in emergency, surprised they can do this - Not common for physicians to misdiagnosis o Study: 85 patients diagnosed w/ conversion disorder  11.8% had developed neurological disorder 2.5 yrs after first exam  rate of misdiagnosis of conversion disorders (that are real physical probs) is 4%  ruling out other medical causes = principle diagnostic criterion in DSM 5 - Difficult to distinguish b/w inds truly experiencing conversion symptoms vs faking symptoms (“malingers” – fully aware of what they are doing, doing it for reason eg. to get out of legal probs) - Factitious disorders – b/w malingering and conversion disorders o Symptoms under voluntary control (same w/ malingering) but person has no reason for voluntarily producing symptoms (except to assume sick role, get more attention) o Symptoms can be extended to family members o Factitious disorder by proxy (Munchausen syndrome by proxy - Adult (usually mom) may make her child sick (caused from mom trying to get attention from child)  Extreme tactics to create appearance of illness in child  Eg. mother stirred her own used tampon in urine sample of child, mix species in child’s vomit  Nature of illness usually hidden – mom makes herself seem like a great parent to med professionals (forms pos relationship w/ them)  to assess Munchausen syndrome by proxy– trial separation of mom and child or video surveillance of child while in hospital  Study: validates video surveillance in hospital rooms of children suspected w/ Munchausen syndrome by proxy  Child suffering from recurring Escherichia coli infections – cameras caught mom injecting her own urine into child’s IV Unconscious Mental Processes in Conversion and Related Disorders - Unconscious cog processes  we are capable of receiving/processing info from sensory channels (eg. vision and hearing) w/o being aware of it o Study: ppl w/ small, localized damager to certain parts of brain can identify objects in filed of vision, but had no awareness that they could see - Study: dif b/w real unconscious processing and faking (malingering) o Hypnotized 2 subjects, making each believe they were blind o One subject told that its very imp that she appears to everyone to be blind (2 person not given these instructions) o Results  Person 1 – underperformed on visual discrimination task (eg. upright triangle task – given 3 shapes, identify upright triangle) – picked wrong shape on almost every trial  Person 2  performed perfectly on visual discrimination tasks – but reported she couldn’t see anything - Study: evaluated man who appeared to have conversion symptoms of blindness o Performed more poorly than chance on visual discrim task  He was malingering – someone who is truly blind would perform at chance level on visual discrim tasks  Ppl w/ conversion symptoms can see objects in their visual field and would perform well on these tasks (but this experience is dissociated from an awareness of sight)  Malingers do everything possible to pretend they can’t see Statistics - conversion disorder may occur w/ other disorders (SD) - rare in mental health settings  but ppl who seek help for conversion disorders more likely to consult neurologists/specialists - high prev in neurological settings – 30% - Study: 10-20% of all patients referred to epilepsy centres have psychogenic (noon-epileptic) seizures - mainly in women (like SD) - develop during adolescence - occur frequently in males during extreme stress o eg. not uncommon in combat soldiers - symptoms will disappear, return later in same/sim form when stressor occurs (eg. Mr. A – dizziness/ringing in ears went away, returned later in form of speech disruption) - 3 yr Longitudinal Study: 88 patients – long-term prognosis poor for CD w/ movement disturbances  resolved in only 5% of patients at follow up - conversion symptoms common in religious/healing rituals o seizures, paralysis, trances – common in fundamentalist religious groups in NA – seen as evidence of contact w/ G-d (seen in high esteem by peers) o don’t meet criteria for disorder unless interfere w/ person’s functioning Causes - Freud – 4 basic processes in development of CD o 1. Ind experiences traumatic event (unacceptable, unconscious conflict) o 2. Represses conflict (b/c conflict / resulting anxiety are unacceptable) o 3. Anxiety inc, threatens to emerge into consciousness, person “converts” it into physical symptoms (relieving pressure of having to directly deal w/ conflict)  reduction in anxiety = primary gain / reinforcing event that maintains conversion symptoms o 4. Inc attention/sympathy from loved ones, may be allowed to avoid dif situation  secondary gain /reinforcing set of events - ind w/ conversion disorder experiences traumatic event that must be escaped at all costs o eg. combat, being exposed to accident/homicide o running away is unacceptable, being sick = socially acceptable o getting sick on purpose is unacceptable, so motivation is detached from person’s consciousness o b/c the escape behav (conversion symptoms) is successful in getting away from traumatic situation, behaviour continues until underlying prob is resolved - Study: 34 child/adolescent patients (25 girls) evaluated after receiving diagnosis of psychologically based pseudo seizures (psychogenic non- epileptic seizures) o Many had other psych disorders – 32% w/ mood disorders, 24% w/ separation anxiety/school refusal o Most patients had substantial stress – inc history of sexual abuse, recent parental divorce, death of close fam member, physical abuse o Results – major mood disorders and severe environmental distress (sex abuse) are common in children/teens w/ conversion disorder of pseudroseizures - Freud’s primary gain o La belle indifference – inds not upset by symptoms o Freud thought that b/c symptoms reflected unconscious attempt to resolve conflict, patient wouldn’t be upset by them  But – patients w/ CD are distressed (eg. Mrs A embarrassed by episodes of speech disruption that she avoided social gatherings ) - Study: compared patients w/ CD and control groups of anxious patients w/o CD o CD showed equal/greater anxiety and physiological arousal than control group - Social/Cultural influences o CD more likely to occur in less educated, low SES - little knowledge re: disease/med illness o Study: 13% of 30 patients w/ motor disabilities due to CD had attended high school, compared w/ 67% in control group w/ motor s symptoms due to physical cause o Prev experience w/ real physical probs (usually in fam members) can influence later choice of specific conversion symptoms – patients adopt symptoms w/ which they are familiar - dec incidence over past decades  knowledge about real causes of physical probs eliminates secondary gain - many dif factors affect CD o ind may have biological vulnerability to develop disorder under stress o exposure to traumatic events = major factor o sometimes interpersonal factors override bio factors Treatment - sim treatment to SD - main strategy – identify/ attend to traumatic/stressful life event (either in real life or memory) and remove sources of secondary gain - 1. Therapeutic assistance to re-experience / relive event (catharsis) o eg. Ms A – CBT involving imaginable exposure to trauma memories  frequency of speech disturbance episodes dec during treatment until Ms A was symptom free! - 2. Must reduce reinforcing / supportive consequences of conversion symptoms (secondary gain) o eg. Eloise – mother found it convenient if Eloise stayed in same place for all of day while mom attended to store in front of house o Eloise’s immobility strongly reinforced by motherly attention o Any unnecessary mobility was punished o Therapist has to work w/ both patient and family to eliminate self- defeating behavs - CBT – 65% of group of 45 patients w/ motor behav conversions (eg. difficulty walking) responded well to CBT o Hypnosis (given to half of patients) didn’t add any benefit to CBT PAIN DISORDER - pain disorder – person may have clear physical reasons for pain (initially() – but psychological factors play major role in maintaining it (anxiety focused on experience of pain ) - DSM IV – might remove it from somatoform disorders and put it in separate section b/c person rarely presents w/ localized pain w/o physical basis - Difficult to separate cases where causes are psychological vs cases from physical causes - Pain disorder = somatoform disorder (ind presents w/ physical symptoms judged to have strong psychological contributions) - DSM 5 proposal – make pain disorder part of larger category called “complex somatic symptom disorder” o Clinician can still specify complaints of chronic pain (+associated anxiety) as main issue - 3 subtypes of pain disorder in DSM IV –includes range of pain caused by psychological factors to pain caused from medical condition - 5-12% meet criteria for pain disorder - imp feature – pains real/hurts regardless of causes - DSM IV criteria  pan disorder is “chronic” when persisted for +6 mos - Difficult to assess whether a somatoform pain disorder ins present o Study: when patients described their symptoms, those w/ physically based pain differed in ways from those w/ pain from psychological facotrs  Physically based pain – usually described clearn localization of pain, used more sensory words to describe quality of pain, better able to link pain to situations that could inc or dec it) - if med treatmens for physical conditions are in place and pain remains, or if pain is related to psychological factors  need psych interventions o eg. med student – had intermittend ab pain for sev weeks, no past history of pain, recently separated from husband – taught relaxation techniques and given supportive therapy to help cope w/ current stressful situation – pain disappeared BODY DYSMORPHIC DISORDER - body dysmorphic disorder (BDD) – ppl think they’re so unable that they’re unable to interact w/ others / function normally out of fear that ppl will laugh at their ugliness o preoccupation w/ imagined defect in appearance (person actually looks normal) o “imagined ugliness” – eg. Uma Thurman Clinical Description - Study: 23 patents w/ BDD o 61% focused on skin, 55% on ahir - fixation w/ mirrors o frequently check imagined ugly feature to see if it changed o others avoid mirrors (phobia) - suicidal ideation, suicide attempts and suicide are common - “ideas of reference” – they think everything that goes on in their world is somehow related to them (and to their imagined defect) - cause disruption in patient’s life – become housebound for fear of showing themselves to pppl - used to be called dysmorphophobia (fear of ugliness ) – used to be thought to rep a psychotic delusional state b/c inds weren’t able to realize that their beiefs were irrational - OCD – do patients really believe in their obsessions or realize that they’re irrational o 10% or less believe their feare about contaminating others or need to prevent catastrophes w/ rituals are realistic/reasonable o major issue of what “delusional” is - Study: 50% of patients convinced their imagined bodily defect was real/reasonable source of concern o Is this delusional?  DSM IV  inds w/ BDD whose beliefs are firmly held that they could be called delusional, should receive a 2 diagnosis of delusional disorder somatic type - no sig differences b/w delusional and nondelusional BDD o delusional type more severe, found in less educated patients o both groups respond equally to treatments for BDD o “delusional” group doesn’t respond to drug treatment for psychotic disorders - DSM V proposal – patients would receive just a BDD diagnosis, whether they are “delusional” or not nd o Practice of giving 2 diagnosis of delusional disorder (a psychotic disorder) should be dropped Statistics - prev of BDD hard to estimate - BDD tends to be kept secret - more common thatn prev thought - w/o treatment tends to be lifelong o eg. patient – had condition for 71 yrs, since age 9 - Study: approx 70% of uni students report some dissatisfaction w/ bodies, 28% meet all criteria for disorder o Studyw as done by questionnaire, could reflect large percentage of students are just concerned w/ their weight - Study: prev of BDD in ethnically diverse sample of 566 adoles b/w 14-19 o Prev of BDD = 2.2%  girls more dissatisfied than boys w/ bodies o Blacksof both genders more satisfied w/ bodies than Caucasians, Asians and Hispanics - not strongly associated to one sex o slightly more f
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