Body Dysmorphic Disorder: Big Eyes

INTRODUCTION:

Directed by the talented visionary Tim Burton, ‘Big Eyes’ (2014) is set in the late 1950s and early '60s. Burton reveals the truth behind the oil painted portraits of individuals with saucer-eyed waifs and the unbelievable fame and success that they brought to the artist Keane.

Distorted perception of an image or physical aspect of a person, where an individual is pre-occupied with a perceived flaw in physical appearance, is known as Body Dysmorphic Disorder [BDD]. Individuals with BDD usually focus on one or more aspects of their appearance, such as skin, nose, hair, eyes (or any other part of their appearance), where they believe to be defective or ugly. They often camouflage their perceived flaw with make-up, hair, or clothing. In the case of the artist, Margret Keane, her unique perception of the world and people around her, is what made her so special.

"Walter Keane: “The eyes are the windows of the soul… That’s why I paint them so big. I’ve always done it that way.”
Margaret Keane: “Why are you lying?”
When Walter presents her paintings as his own, Margaret is confused and surprised. She cannot understand why he would lie about something like this, especially at her expense."

BACKGROUND INFORMATION:

The DSM-5 defines Body Dysmorphic Disorder or (BDD) as a severe mental illness characterized by chronic, often delusional, preoccupations with non-existent or slight flaws in appearance that extend far beyond vanity. People with BDD frequently compare their appearance to others and check their appearance in mirrors or other reflective surfaces. They may change their body position to only allow people to see them from certain angles or in certain lighting conditions. Other behaviors include mirror avoidance, skin picking and seeking out dermatologists or plastic surgeons with the hope they can overcome the distress by changing the perceived defect. [A]

Whenever a body part becomes the central focus of concern this is typically considered to be a ‘cosmetic concerns’ in people struggling with BDD. Consumed by their imagined deformities, people with this condition often experience severe depression, and engage in substance misuse and life-threatening behavior. Their degree of anguish and distress is such that it interferes with their day-to-day activities such as work, school, or social situations. which can result in severe functional impairment and suffering. Some individuals become so overwhelmed and sick that they become housebound [A].

"Margaret Keane: “These paintings are a part of my being. Maybe I could sign it myself.”
Walter Keane: “That sounds a big confusing. Doesn’t it? Keane means me.”
(When Margaret suggests that she should finally take the credit for her work, Walter isn’t having any of that. While he claims he doesn’t want to confuse anyone, he also doesn’t want to lose the spotlight.)"

"Walter Keane: “Sadly, people don’t buy lady art for paintings. The painting says Keane. I’m Keane. You’re Keane.”
Walter explains to Margaret why he is telling everyone that he painted the Big Eyes instead of her. He believes that in order to be commercially successful, the painter must be male."

Treatment for BDD includes a combination of counseling and prescribed antidepressant medications. Talk therapy with a primary focus on modifying negative thoughts, behaviors, and emotional responses associated with psychological distress, Cognitive Behavioral Therapy [CBT], is one type of counseling that might work for individuals struggling with BDD. Others include Behavioral therapy where the patient and the therapist focus on modifying harmful behaviors associated with psychological distress. With psychotherapy, treatment of mental or behavioral disorders is through talk therapy. Typically, clinical psychologists treat mental disorders through talk therapy whereas psychiatrists, tend to prescribe medications more often.

"Walter Keane: “Do you want to give back the money? If you tell anyone, this empire collapses.”
Margaret Keane: “If that’s the price…”
-Things reach a breaking point between Margaret and Walter. She’s ready to spill the beans on being the true artist behind the Big Eyes, regardless of the consequences of that revelation. –

"Margaret Keane: “This is what it’s come to, huh? You are the only living soul I can tell my secret to. I painted every single one of them, every Big Eye, me, and no one will ever know but you.”

-In speaking to her poodle, Margaret is honest with the dog as to the true creator of the best-selling paintings. While she can tell this secret to her dog, it’s something that she fears the public can never know. –

Walter explains to Margaret why he is telling everyone that he painted the Big Eyes instead of her. He believes that in order to be commercially successful, the painter must be male."

 

These medications include: ‘Selective Serotonin Reuptake Inhibitor’ (SSRI) which function to ease symptoms of depressed moods and anxiety, ‘Sertraline’ [also known to treat depression, OCD, and PTSD] is also known as ‘Zoloft’, ‘Escitalopram’ [treats anxiety and depression in addition] commonly known as ‘Lexapro’, and lastly, ‘Citalopram’ is another common medication for BDD [also treats depression] known as ‘Celexa’[D].

 Margaret Keane: “It’s like a mirage. From the distance, you look like a painter, but up close there is not much there.” Margaret describes Walter, with whom she’s now seeing as someone who crossed her, instead of a doting husband. He paints him as a fraud, someone who appears to be something he’s not from far away but one who is transparent up close."

 "Walter Keane: “What’s your name?”
Margaret Keane: “Margaret. Wouldn’t you rather flirt with those girls down there?”
Walter Keane: “No, I like you, Margaret.”
…
DeAnn: “Wow, this is all happening mighty quick.”
Margaret Keane: “I am a divorcee with a child. Walter is a blessing.”
Margaret and Walter meet in San Francisco and immediately hit it off and after a short time, they are married. Margaret’s friend DeAnn is critical of the sudden union but Margaret sees it as her only choice.)"

RESEARCH:

As 1-2% of the population is diagnosed with BDD and where 6-14% of individuals within mental health settings reveal to have an anxiety or depressive disorder, 10-15% from dermatology settings, and 6-15% in cosmetic surgery settings, researchers have set out to find the neurobiology behind BDD. A breakthrough in brain circuitry related to BDD will help to discover more effective approaches to treat the condition. BDD is not simply a clinical variant of OCD, and in the past few years researchers have begun to explore ways to tailor treatments to specifically address people's excessive concerns over their appearance. Similar characteristics in BDD are also found in individuals with OCD. Often, both are also managed in the same way— through a combination of antidepressants (typically at high dosages) and talk therapy. [B]

A study published in June 18, 2013, set out to investigate the relationship (s) between white matter microstructure of individuals with BDD and clinical symptoms expressed in such individuals. The primary focus of the study was in randomized controlled trails of psychotherapy. From these studies, researchers have been scanning brain activity -or lack thereof- in patients for a deeper understanding of the complex neuronal circuitry for BDD. This is the first study examining white matter in individuals with BDD, using diffusion tensor imaging. The results suggest an association between poor insight and fiber disorganization in tracts connecting visual with emotion/memory processing systems. [B]

The forerunners of this breakthrough in scientific research were, Dr. Sarah Madesen, Dr. Jamie Feusner, and their colleagues, who are officially the first to date to conduct the largest neuro-imaging analysis on BDD individuals which was also the first study to analyze cortical thickness.

The results reveal no significant abnormalities in the gray matter volume(s) nor in cortical thickness between the ‘Control Group’ (aka: the ‘healthy/ normal’) group in comparison to individuals with BDD. 
What they did discover though is that there is in fact a link between the amount of anxiety to gray matter thickness and volume of BDD brains. These variations were found in different regions of the brain. Subsequently, these results suggested that the patterns of brain structure in BDD vary with degree of clinical symptoms, rather than there being major differences from healthy controls. In previous discrepant results of various studies focused on the volumes of thickness in different brain regions could be due to the small sample sizes. No study has investigated cortical thickness of BDD, until now. [B]

"Jane: “I remember when my mamma painted that.”
Walter Keane: “You’re confused. I painted that.”
When Margaret’s daughter, Jane, mentions that she remembers when mother Margaret painted a specific piece, Walter corrects her. Both Margaret and Walter lie to the child in order to preserve the business they built."

THE PROCEDURE:

Participants included 49 medication-free, right-handed individuals with DSM-IV BDD and 44 healthy controls matched by age, sex, and education. Using high-resolution T1-weighted magnetic resonance imaging, we computed vertex-wise gray matter (GM) thickness on the cortical surface and GM volume using voxel-based morphometry. Volumes of cortical and subcortical regions of interest were also computed. In addition to group comparisons, associations between severity of symptoms, insight, as well as anxiety levels within the BDD group. [B]

In BDD, greater anxiety was significantly associated with thinner GM in the left superior temporal cortex and greater GM volume in the right caudate nucleus. There were no significant differences in cortical thickness, GM volume, or volumes in regions of interest between BDD and control subjects. Subtle associations with clinical symptoms may characterize brain morphometric patterns in BDD, rather than large group differences in brain structure. [B]

According to data compiled by Phillips and her colleagues, the suicide rate of those with BDD is at least 22 times greater than that of the general population — making BDD one of the most lethal psychiatric conditions. Although, up to 2% of the overall population is affected, most cases go unrecognized and untreated. Instead of seeking the help of mental-health counselors, many people with BDD visit cosmetic surgeons, dermatologists and dentists. Most patients who have appearance-enhancing procedures, however, simply shift the focus of their concerns or they continue to worry about imperfections in the treated area.

"Priest: “What is troubling you?”
Margaret Keane: “I lied to my child and I’m just not that kind of person.”
Priest: “Is your husband that kind of person?”

Margaret has regret over the fact that she lied to daughter Jane about the true artist behind the Big Eyes. As the priest mentions, perhaps her husband is the bad influence pushing her to do such a thing. 10. Walter Keane: “That’s an outrageous statement!”
In court, Walter objects when he is accused of lying about the true painter of Big Eyes. This epic court battle has been a long time coming and is bound to get ugly fast."

 

STUDY #1:

A team lead by Wilhelm discovered that half of their participants showed improvements in their symptoms as soon as just 12 weeks of CBT (location of trails was in Massachusetts General Hospital and Butler Hospital in Providence, Phillips). Meanwhile, the participants that made up the 12% who did not go to therapy did not show much improvement.

After these results, all participants were then given a 22-session course of CBT.  Out of the 29 participants, 24 responded favorably. With such a dramatic response rate, Wilhelm and Philips had to find out whether it was because of CBT specifically or because of the therapeutic experience. To do this, they organized a larger, randomized trial of 120 participants.

Currently, Philips has presented results of his own study that revealed relapse rates among BDD individuals after they stopped taking anti-depressants. Wilhelm, on the other hand, has been conducting a placebo-controlled trial of 50 participants to test whether a neurotransmitter-activating drug known in the scientific field as “D-Cycloserine”. This drug can enhance behavioral learning which is part of CBT (the strategy has also worked in anxiety disorders and OCD treatments).

Phillips is also probing the genetics of BDD in search of new drug targets. In collaboration with a team at the University of Toronto in Canada, she identified a gene that encodes a brain receptor involved in the transport of the neurotransmitter γ-aminobutyric acid (GABA) that may be implicated in the development of the disorder.

The researchers are now engineering mice with mutations in this gene to create the first BDD-specific animal model. They plan to assess how early life stressors in these mice affect the development of grooming behaviors (people with BDD are commonly preoccupied with grooming). Eventually, they hope to test which drugs offer symptom relief too.

STUDY #2:

A study led by psychiatrist, Christian Rück, and his colleagues at the Karolinska Institute in Stockholm are trying to make CBT more available to patients since there are very few clinical centers that specialize in BDD. By providing this service to individuals struggling with BDD or other mental health disorders, will give patients an opportunity to leading functioning healthy lives.

Their goal is to deliver CBT over the internet which they will call ‘iCBT’. Even when patients have access to such therapy options, they feel too ashamed to openly discuss their struggles with a therapist. Dr. Ruck and his team’s goals will help so many lives world-wide. After conducting a 3-month pilot study of the iCBT program, out of the 22 patients, 18 of them responded positively to therapy. In their randomized trail of iCBT program with a total of 94 participants, iCBT outperformed supportive psychotherapy.

The way in which iCBT works is that it is really a web-based protocol that allows for the therapist to be in-touch with their patients through a build-in e-mail system. However, in the mental health profession, each liscensed mental health provider/professional spends an average of 10 minutes with each case per week. Typically, these sessions should last between 45-50 minutes. With iCBT, a few people could treat a whole nation in an effective and even more productive fashion.

STUDY #3:

Majority of scientists are now using neuroimaging to their advantage in their pursuit in explaining the biological basis of BDD and its varied responses to therapy. Psychiatrist Jamie Feusner at the University of California and his colleagues are just some of these scientists and they have already found connectivity patterns between brain regions in people with BDD which are different from those of individuals without body-image problems — and that brain activity is responsible for visual stimuli.

This new visual approach to better understanding the human brain could be the key as to why individuals struggling with BDD find themselves overwhelmed with their physical appearances. Feusner has been testing whether a certain type of testing in perceptual retraining involving those designed to help individuals adjust their visual focus with detail-oriented to global processing to balance this visual focus.

In simpler terms, he and his colleagues are trying to re-wire the brain. For example, one exercise attempted to modulate eye gaze by asking individuals to view a digital photograph of their face and then hold their visual focus within a target circle between the eyes (instead of on, say, a barely visible facial scar). Another presents the same picture but for only a split-second, forcing the brain to process the face more holistically. If such interventions lessen symptoms of this disorder, Feusner says, they would be “the first to be directly informed by knowledge of aberrant neurobiology in BDD.”

 

CONCLUSION:

Lisa Ishii, a plastic surgeon at Johns Hopkins School of Medicine in Baltimore, Maryland is calling on her fellow physicians to decline operations on individuals with BDD. They do not need cosmetic surgery, but instead need psychiatric care. Ishii and her team have been using a two-stage screening process to make sure patients do not have BDD to those who are just dissatisfied with a certain physical trait.

The first step is a questionnaire which is then followed up by a second step that is known as the ‘clinical interview’. Using this approach to treat patients helps people find the unique and proper type of care for each specific case. This also protects plastic surgeons in avoiding lawsuits, being physically threatened or kill by people dissatisfied with BDD (such instances although extreme, do in fact happen in real life).

Links:

[A] http://www2.semel.ucla.edu/edbdd

[B] http://www.ncbi.nlm.nih.gov/pubmed/25797401

[C] http://www.nature.com/nature/journal/v526/n7572_supp/full/526S14a.html?foxtrotcallback=true 

[D] http://www.mayoclinic.org/diseases-conditions/body-dysmorphic-disorder/home/ovc-20200935

*Please note! These images are not mine. They were found on various tumblr, pinterest, google image sites! If any are yours’ please let me know so that I can give you credit for them! Also, the people in the images have no relation to the diseases, illnesses, or cancers I write about. Thanks so much & enjoy~

*Quotes by:  http://www.ranker.com/list/big-eyes-movie-quotes/movie-and-tv-quotes