Case Study 6: Body Dysmorphic Disorder

Body dysmorphic disorder, also known as BDD, is a mental disorder that causes an individual to
imagine a defect in their appearance and then become excessively preoccupied with the
perceived imperfection. BDD can be classified as an anxiety disorder because its victims can
experience difficulty focusing, fears of many different things, find themselves engaging in
compulsive behaviors, and are sometimes so consumed with their imagined defect they will
avoid being seen. Individuals, like Tina, who suffer from this disorder can also compulsively
perform rituals to help feel relief from the distress their imagined defect can cause. BDD
commonly co-occurs with OCD or in people who have family members that have experienced
OCD. A study discussed in Abnormal Psychology: An Integrative Approach (168) states that
patients with BDD and OCD have similar abnormal brain function. In case study 6 the story of
Tina Mobley is told and it exhibits how BDD is more like an anxiety disorder. The story also
exemplifies the similarities between BDD and OCD. In Tinas case, BDD causes her to perform
compulsive behaviors like constant mirror checking to monitor the imagined defect and long
bouts of skin picking to remove, fix, or relieve appearance-related distress caused by the
imagined defect.
Body dysmorphic disorder can also cause a lot of social anxiety or social phobia, this is
extremely apparent in Tinas case. Tina was so consumed by her disorder that she would turn
down opportunities for promotion, avoid talking to her sister, and would often call in sick to
work. She had these social phobias because she would become anxious about a presentation and
pick her skin for relief which would work temporarily then Tina would realize the impact of her
skin picking and feel the need to stay inside and prevent others from noticing the defect or the

impacts of her skin picking. In Tinas case the anxiety disorder that her BDD was most like
would be social phobia that was caused by her obsession with this perceived defect.
Treatment for body dysmorphic disorder can include serotonin reuptake inhibitors (SRIs)
and cognitive-behavioral therapy (CBT). Some individuals who suffer from BDD will treat
themselves or receive care that is not from a psychologist. Many will get plastic surgery to repair
the defect but that will only provide temporary relief. Some individuals may even perform the
plastic surgery upon themselves if they do not have the funds to pay for real surgery. Tina was
treated with SRIs and cognitive-behavioral therapy. The most helpful parts of her CBT were selfmonitoring and habit reversal training. Self-monitoring is crucial to improvement because it
shows Tina and other patients how often and what types of BDD thoughts are occurring. Once
they understand the types of thoughts they are having they can begin to restructure the thoughts
to less negative ones. For example, Tina once reported thinking that her sister did not return her
call because she hated her due to her skin blemish. CBT taught Tina to take that personalization
thought and make a more positive thought, my sister did not return my call because she is busy
with work today. When a patient is treated with habit reversal they learn alternatives to the
ritualistic behavior they previously had. Tina learned some strategies like keeping the bathroom
lights off and applying lotion to her hands to prevent being triggered to pick. Habit reversal
strategies can also be used to help patients ride out their urges. Once the time patients used to
spend doing compulsive checking or picking has been reduced, the therapist and the individual
can find something healthier to fill their time with.
Body dysmorphic disorder affects men and women differently because society has made
the things that could be considered a defect to women different than what men consider a defect.
Men are more concerned with the build of their body, muscle definition, genitals, and the look of

their hair. They imagine to experience defects involving having small muscular stature, thinning
of the hair, and defects involving the genitals. In lecture, Professor Watkins mentioned that when
men get teased for being obese it is at a body mass index much higher than that of women who
could be teased. The BMI that men get pressured at is around 37 which is class 2 obesity, for
women it is a BMI of 27 which is considered simply overweight. The behaviors that men and
women perform to feel relief from appearance-related distress is also going to vary based on
what society has created as right and wrong for them. Most women who believe their defect to be
a weight issue will and are more likely to develop eating disorders while men more commonly
will create habits of bodybuilding.
Diagnosing BDD is difficult because many people dont realize this is a mental health
disorder or they receive help from plastic surgeons versus a psychologist. Some things that we
can look out for are friends or people who are constantly checking their reflection in the mirror,
always engaged in negative body talk about a specific body part, and individuals that suffer from
BDD see a defect that no other person sees. Some questions that a health care provider could ask
to understand the severity of the body dysmorphic disorder are: How is work going? When was
the last time you went out in to public? When was the last time you did something you loved?
These questions could lead someone to understand how severe the BDD is because they show
the anxiety an individual suffers while doing basic things like work or going to the store.

Case Study 7: Physical Abuse of Adult (Domestic Violence)

Domestic violence has been a pressing issue for many years. The issue has begun to
increase epidemically, in 1980 up to 16% of homes reported an act of violence toward a spouse
in the last year. Recent research states that nearly 41% of women are victims of domestic
violence at some point in their life. Current research indicates that the rates of domestic violence
fall evenly across the different genders. Some cultures even show higher incidences of women as
the abuser. A couple factors that could cause this to be true include past abuse and cultural
differences. Individuals that suffer from abuse as a young child or in past relationships have risk
factors of expressing abuse. Those who have suffered abuse as a child may have never learned
how to properly regulate or express feelings of anger causing them to react with aggression. The
inability to express himself was one of Scotts biggest problems. Scott was scared to be assertive
and state his point, causing him to use aggression to get his point across (Casebook 90). Past
abuse from other relationships can also make an impact on a persons expression of domestic
violence. Individuals who have been abused in the past may use abuse in a new relationship.
Those who have been abused could become abusive to insure no one else will hurt or hit them,
this trend is especially apparent in women.
Cultural differences play a large role in domestic violence. Some cultures view women as
unimportant others see them as decoration. Cultures that view women in this way will have
larger incidences of abuse because they dont view it as a negative act. Another way culture or
race can affect the occurrence of domestic violence is the different ways stressors affect people.
In the Casebook a study shows that different racial groups cope with work stressors differently.
Anglo-American groups who were dealing with work stressors were associated with increased
levels of drinking but not an increase in marital violence. Compared to Hispanic-American

husbands whose response to work stressors is associated with elevated levels of drinking and
domestic abuse. This study shows a relationship between race, culture, and incidences of
domestic violence.
Many victims of abuse will remain in the household with the abuser despite what has
occurred. Women can remain in the home for many reasons including lack of self-esteem, not
having the funds to leave, and fear of what could happen if they do leave. Women who are
abused often have low self-esteem due to the abuser often saying how horrible, incompetent, and
unworthy an individual may be. Men are often the person in a relationship that makes the most
money meaning a women would not have the money to live on their own. Also the abuser is
often a controlling person, whether the abuser is a man or woman, and it is not uncommon for
that individual to have complete control of the familys funds. Another reason a victim may
remain in the home after an episode of abuse is because the individual or the individuals family
was threatened if they mentioned leaving. Abusers frequently have a controlling personality and
will want the victim to remain in the home so he or she has the opportunity to control an
individual.
Abuse in relationships can run a cycle that consists of tension build up, abuse incidence,
reconciliation, and the calm. This cycle is also often a reason victims remain in the household.
The cycle works by having tension or stressors build up resulting in an episode of abuse. The
abuser then feels remorse and apologizes, gives presents, or reassures it will never occur again.
Then the relationship is calm and in a good state until stressors build up again. The best response
to the initial abuse is to leave. Those who abuse once are likely to abuse again, no matter what an
individual may promise.

Certain personality characteristics and psychological disorders can increase the likelihood
and frequency of violent acts by an individual. Patients with severe psychological disorders that
effect emotional expression, like BPD, can have a difficult time finding the correct way to
express how they feel or what they need so resorting to aggression may be the only way they
know how to communicate, this is exemplified in Scotts case. When working with patients who
are being treated for domestic aggression and other psychological disorders it is important to first
address the behaviors that cause harm to others. In Scotts case the therapist addressed the
behaviors that led Scott to be abusive towards his girlfriend then moved on to the behaviors that
were characteristic of BPD. The two treatments overlapped greatly because in treating Scotts
domestic aggression the therapist also addressed his impulsiveness, a trait of BPD. Personality
traits commonly seen in female abusers include anger and hostility, control needs, and
unassertiveness. Characteristics noticed in male abusers consist of difficulty expressing affection,
struggling to form trusting relationships and an inability in handling marital conflict through
discussion. These are some traits that have been associated with spousal aggression (Casebook
100).

Case 14: Alcohol Dependence

Alcohol abuse in college students presents differently than what the DSM-IV-TR
identifies as alcohol abuse. In order for an alcohol abuse diagnosis to be used a patient needs to
be experiencing many problems as a result of the alcohol use. This is where the difference
between alcohol abuse and college binge drinking exists. The diagnosis of alcohol abuse calls for
failure to succeed in major obligations, use of alcohol in physically hazardous situations, legal
problems, and continued use despite social or interpersonal problems. College binge drinking
habits should not include a person failing to fulfill major obligations, like school. Only binge
drinking should not involve repeated social or interpersonal problems. Isolated acts of drunk
driving and legal problems can occur with binge drinking but alcohol use usually decreases after
these situations.
This is where the difference between alcohol abuse and college binge drinking occurs. It
becomes alcohol abuse when repeated legal problems become an issue. A minor in possession
(MIP) or minor in consumption (MIC) charge may happen once to a college student after an
unfortunate night of binge drinking. When a person continues to abuse alcohol and is getting
repeated charges for things beyond MIPs and MICs like disorderly conduct, it has become
alcohol abuse. Binge drinking usually does not involve a person whose social and interpersonal
lives have suffered from alcohol use. The college environment is conducive to binge drinking,
but it does not support constant inebriation. Always being drunk would not allow a student to
succeed in classes nor would social circles allow for a friend to constantly be intoxicated.
Just like how the college environment supports binge drinking, which causes more people
to drink, a home environment that has a high prevelance of alcohol can influence members of a
household to abuse alcohol. A patient that is in treatment for alcohol abuse needs a supportive

community around them, which makes a persons familial relationship very important. When a
patient has a negative family environment those emotions could potentially drive someone
towards alcohol rather than away from it. For example, Steve had a family environment that was
very negative. Most the paternal family members he had were physically and/or sexually
abusive. His family also failed to tell him about his mothers death, leading him to drink more
out of frustration and grief. Supportive families can be helpful in treatment by providing positive
experiences for someone who is experiencing life without alcohol as a crutch. Being surrounded
by a positive social environment would cause similar advantages in a persons recovery. Having
a positive social environment would also allow recovering alcoholics to have a group of people
that would be helpful in finding a neutral environment.
A major cause of relapse in alcohol abusers is being put in a situation where saying no is
hard and mastery of saying no has not yet been achieved. Relapse may also occur in patients that
are in an environment that create negative experiences and drive them to drinking. Patients who
are recovering from alcohol dependence should have the skills to be in a bar and know how to
cope with an urge. Eventually, when the patient and therapist feel it is appropriate, an occasional
drink should be allowed. The thought of having an occasional drink or being in a bar should not
cross the mind of a patient until they have been in treatment for an extensive amount of time. By
that time, patients should have the skills to control urges and deal with any situation that may
arise. Allowing patients that are recovering to take an occasional drink, occasional being once
every three or four months at special occasions, will help patients continue to solidify the toolbox
that people like Steve have created.
The laws, culture, and religious beliefs of a person, country, or race can play a large role
in the opinions one might have about alcohol. In countries like Europe where alcohol use is very

prevalent but alcohol dependence is rare it is because at a young age people are taught the proper
way to use it. Alcohol is not used as a problem solving mechanism or a crutch in stressful
situations. The attitude towards alcohol in places like Europe is very different than what is seen
in America. Alcohol abuse and anxiety disorders often co-occur because people may use alcohol
as a way to cope with the anxiety they experience in various situations. In Steves case his lack
of social skills drove him to drink, as did his inability to sleep when he experienced nightmares
about past sexual and physical abuse. These are two situations where anxiety or stress related
disorders drove Steve to alcohol in order to cope. Anxiety disorders and alcohol dependence
often happen together. The effects of alcohol can ease anxiety symptoms. In Steves case the
alcohol helped him sleep after experiencing a nightmare. Mood disorders also play a role in
alcohol dependence but they sometimes occur after alcohol abuse has already been a problem.
The alcohol will suppress function in parts of the brain that help a person control their emotions
leading to impulsiveness. Alcohol abuse can lead to disorderly conduct and aggression towards,
commonly against loved ones. Domestic violence occurs in relationships, like Steves, when a
spouse is an alcohol abuser.

Case Study 15: Borderline Personality Disorder

Borderline personality disorder (BPD) is a disorder that involves emotional instability
and difficulty keeping healthy relationships. People with this disorder will often engage in selfmutilating and/or suicidal behaviors. BPD often co-occurs with depression, eating disorders, and
other mood disorders. Up to 20% of people with borderline personality disorder that took part in
a study also have bipolar disorders (Casebook 211). BPD presents with higher rates of suicide
because people who suffer from this disease think irrationally and are emotionally unstable. In
Robins case, interactions with close friends or family members would leave her feeling unloved,
which would lead her to self-mutilate or have urges to commit suicide. In this case the suicide
was not preventable. Therapists and doctors tried to talk Robin down and show the value in
living but irrational thoughts and an inability to function well in relationships eventually led to
her demise. This irrational thinking is one reason that individuals who suffer from BPD have
higher incidences of suicide.
When people are suicidal or threatening self-mutilation it is important to convince them
of reasons not to commit suicide or hurt themselves. Once the episode of suicidal behavior has
subsided the next, and most important, step is to identify what triggers the urges to commit
suicide. Robins therapist spent time identifying her triggers by having Robin self-monitor.
Triggers that have been identified for this patient include interpersonal relationships. Another
way to respond to patients who are in a long-standing pattern of suicide is to look for behaviors
or reactions from therapists, nurses, or family members that could be reinforcing the selfmutilating or suicidal behaviors. In this case study it confirmed that the hospitalization was
reinforcing the behavior for Robin by providing attention or negative strokes. It is known that
large majorities of people who are suffering from BPD have a history of abusive parents or

broken homes. It is a trait of abuse victims to search for attention from people around them.
Once individuals find behaviors, negative or positive, that cause people to give attention the
victims will continue to behave in that way.
Borderline personality disorder and dissociative identity disorder both have dissociative
properties but in DID the patient embodies different personalities. For example, one person can
have 3 different personalities that can all have different names and characteristics. Abnormal
Psychology: An Integrative Approach (201) uses an example of a man who has an aggressive
personality named Usoffa Abdulla, a rational and calm Sammy, and King Young personality that
is in charge of all sexual activity. The dissociative behaviors in BPD are different because it
involves patients having a lapse in consciousness. Patients with BPD do not have a disruption in
identity as patients with DID do.
There is one large similarity in risk factors for borderline personality disorder and
dissociative identity disorder. Both have been studied to present in patients who have a
background of abuse. The abuse that DID is correlated with is much worse than the abuse BPD
has been correlated with. It is suggested that the individuals who suffer from dissociative identity
disorder create these personalities to escape from the abuse or traumatic events. In the case of
BPD it is suggested the emotional instability also comes from a background in abuse but in a
different way. Individuals who suffer from BPD may have had parents that would react to the
child in a way that made that individual feel their reactions to a situation were invalid. This
results in individuals being unable to trust their emotions and consequentially a person would
distrust their internal cues and search for them in the surrounding environment causing a reliance
on others and the inability to form a sense of self. The consequence of this is difficulty forming
relationships because that requires a stable sense of self. Another consequence of being raised in

an environment like this is that attention seeking behavior like tantrums and loud displays of
emotion are the only way patients know how to get attention.
DID and BPD also have very different genetic influences. Patients with borderline
personality disorder often have family members that suffer from BPD or have family members
that suffer from other mood disorders, suggesting a relationship between BPD, other mood
disorders, and heredity. Identical twin studies have also supported a genetic role in the on-set of
borderline personality disorder. Genetic studies have not gone as well for DID, research has
been unable to find identifiable causal factors for heredity but there are heritable traits that can
increase vulnerability. Traits like suggestibility, tension, and responsiveness to stress may
strengthen a persons chance of DID. The similarities in risk factors for these disorders are
apparent but the differences in heritability are striking and suggest a lack of commonality.
BPD is much more relevant in women because society has more regulations for a how a
women should behave. These social norms push women to conform to specific standards.
Mentioned earlier is the influence being unable to form a sense of self can have on the
expression of BPD. The social norms in this world contribute greatly to the disproportionate
rates of BPD in men and women.