Psychological Applications of CBT

**45**

**Chapter 4**

**Abstract**

A Distorted Body Image: Cognitive

Behavioral Therapy for Body

*Norzihan Ayub, Patricia Joseph Kimong and Guan Teik Ee*

Body dysmorphic disorder (BDD) is one of the mental disorders that warrant more research due to the current challenges and complexity of human life. A search through Medline, Academic Search Premier, PsycINFO, and PsyArticles, using "body dysmorphic disorder" and "intervention" keywords, showed that a total of 186 articles had been published for the past 25 years. BDD was added to the obsessive-compulsive and related disorder spectrum in the *Diagnostic and Statistical Manual of Mental Disorder-5* (2013). BDD is a preoccupation with an imagined defect in physical appearance by individual who looks normal which causes low self-esteem and co-morbids with other mental health problems. Individuals with BDD often end up with dermatological treatment and cosmetic surgery. However, in most cases, they frequently experience a dissatisfaction with the results and worsen the individual condition. Therefore, psychological intervention is needed to treat individuals with BDD to combat their negative perceptions on physical appearance. Research has shown that one of the effective interventions in treating individuals with BDD is cognitive behavioral therapy (CBT). Some techniques that are recommended are psychoeducation, restructuring cognitive, exposure and ritual prevention, and others. This paper aims to discuss the clinical diagnosis and

Dysmorphic Disorder

CBT intervention as a treatment for individual with BDD.

functionality, then it is considered a problem and pathological.

skin picking, obsessive-compulsive disorder

**1. Introduction**

**Keywords:** body dysmorphic disorder, cognitive behavioral therapy, body image,

Body image is one of the first individual characteristics noticed by others and has an important impact on self-image and social interactions. Research study revealed that there is a relationship between self-esteem and body dissatisfaction. This proves that beauty has a connection with self-esteem and self-image [1]. Body image is not just a cognitive construct but also a reflection of attitude and interaction with others. Being concerned and worried about the appearance and body image is normal and common among many people, mostly in female. However, if the individual is overly worried and concerned and affects a person's

Body image encompasses perceptions, thoughts, and feelings about the body that are influenced by development, perception, and sociocultural factors [2]. In some

**Chapter 4**

## A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder

*Norzihan Ayub, Patricia Joseph Kimong and Guan Teik Ee*

### **Abstract**

Body dysmorphic disorder (BDD) is one of the mental disorders that warrant more research due to the current challenges and complexity of human life. A search through Medline, Academic Search Premier, PsycINFO, and PsyArticles, using "body dysmorphic disorder" and "intervention" keywords, showed that a total of 186 articles had been published for the past 25 years. BDD was added to the obsessive-compulsive and related disorder spectrum in the *Diagnostic and Statistical Manual of Mental Disorder-5* (2013). BDD is a preoccupation with an imagined defect in physical appearance by individual who looks normal which causes low self-esteem and co-morbids with other mental health problems. Individuals with BDD often end up with dermatological treatment and cosmetic surgery. However, in most cases, they frequently experience a dissatisfaction with the results and worsen the individual condition. Therefore, psychological intervention is needed to treat individuals with BDD to combat their negative perceptions on physical appearance. Research has shown that one of the effective interventions in treating individuals with BDD is cognitive behavioral therapy (CBT). Some techniques that are recommended are psychoeducation, restructuring cognitive, exposure and ritual prevention, and others. This paper aims to discuss the clinical diagnosis and CBT intervention as a treatment for individual with BDD.

**Keywords:** body dysmorphic disorder, cognitive behavioral therapy, body image, skin picking, obsessive-compulsive disorder

#### **1. Introduction**

Body image is one of the first individual characteristics noticed by others and has an important impact on self-image and social interactions. Research study revealed that there is a relationship between self-esteem and body dissatisfaction. This proves that beauty has a connection with self-esteem and self-image [1].

Body image is not just a cognitive construct but also a reflection of attitude and interaction with others. Being concerned and worried about the appearance and body image is normal and common among many people, mostly in female. However, if the individual is overly worried and concerned and affects a person's functionality, then it is considered a problem and pathological.

Body image encompasses perceptions, thoughts, and feelings about the body that are influenced by development, perception, and sociocultural factors [2]. In some

people, perception has been shaped in such a way that it contradicts with reality. One of the most common forms of this disorder is body dysmorphic disorder (BDD). BDD is a severe disorder defined by a preoccupation with perceived imperfections in appearance and resulting in repetitive behaviors, which also causes a clinically significant distress or functional impairment [3]. BDD also has a high rate of suicidality [4, 5]. BDD typically begins during early adolescence and appears to be common in adults. BDD, previously known as dysmorphobia, represents a psychotic delusional state, whereby the individual was unable to realize, even for a fleeting moment, that their ideas were irrational. Individuals with BDD believe they looked ugly or unattractive when in reality they look normal and attractive. Many people with BDD will seek unnecessary dermatologic, dental, and other cosmetic treatments in hopes of removing their negative perceptions on physical appearance. These procedures have poor outcomes and lead to individuals distress, often worsening the symptoms and leading to the dissatisfaction and loss of self-esteem [6]. Feelings of frustration, hopelessness, or shame resulting from engagement in or disturbance of rituals can also lead to anger outbursts and may involve physical aggression [7].

### **2. Diagnosis and clinical assessment of body dysmorphic disorder**

Previously, BDD was considered a somatoform disorder because its central feature is a psychological preoccupation with somatic issues. However, increasing evidence has indicated it was more closely related to obsessive-compulsive disorder (OCD), accounting for its relocation to the obsessive-compulsive and related disorders section in the *Diagnostic and Statistical Manual of Mental Disorders-5* [3]. The diagnostic criteria of BDD are as follows:

#### **2.1 Appearance preoccupation**

Individuals with BDD are constantly preoccupied and persistently complaining about their appearance which they deem horrible and intrusive [8]. Individuals with BDD exhibit perfectionistic thinking and maladaptive attractiveness beliefs [9]. The average number of body areas that is of a concern to these individuals was five to seven, and preoccupation may focus on any areas of the body and commonly involves the face, nose, hair, skin, breast, teeth, and others [3]. However, some can concern only one area. Concerns range from looking unattractive to looking disgusting. These thoughts are very distressing and are associated with a feeling of low self-esteem, rejection sensitivity, embarrassment, and shame [10]. Generally, they spend at least an hour a day of thinking about the supposed appearance flaws. On average, they will spend between 3 and 8 hours a day on this [10]. Some individuals are also concerned about the perceived asymmetry of body areas. A study showed that females with BDD were more likely to be preoccupied with their hips, weight, breasts, legs, pick their skin and disguise with makeup, while males with BDD were more likely to be preoccupied with their body build, genitals, and hair thinning [11, 12]. Muscle dysmorphia, a form of BDD occurring mostly in male individuals, consists of preoccupation with the idea that one's body is too small or insufficiently lean or insufficiently muscular. In reality, these individuals actually have a normal-looking body and are muscular. Some are also very preoccupied with other areas such as their hair and skin. A majority of them also practices diet and exercise extremely that in turn leads to bodily damage [3].

**47**

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder*

Individuals with BDD also perform ritual behavior by mirror checking or compensating in attempts to alleviate their concerns and anxiety. Excessive grooming, camouflaging, and skin picking are also common in BDD [8, 13]. Some individuals are excessively tan, for example, to darken "pale" skin or diminish perceived acne. In addition, some individuals repeatedly change their clothes such as to camouflage the perceived defects, or some individuals compulsively shop for their beauty products [3]. Many of these behaviors are considered compulsive, in that they are

**2.3 Distress or impairment in social, occupational, or other important areas** 

People with BDD also have the idea of reference which means they think everything that goes on in their world is related to them. This thinking and perception can cause disruption in their lives. Impairment in functioning can include problems with any aspect of social functioning that is caused by BDD, such as problems with relationships, socializing, intimacy, or difficulty being around other people. It also includes problems with the ability to function in a job, academically, or in one's role in life [14]. Among adults, BDD results in high rates of occupational impairment, unemployment, social dysfunction, and social isolation [15]. Similarly, BDD in youths is associated with major functional impairment, including reduced academic performance, social withdrawal, and dropping out of school [16]. They may even become housebound [8]. Overall, individuals with BDD have a markedly poor quality of life.

Individuals with BDD also avoid some social situations because they feel ashamed and embarrassed about their appearance. They are also concerned and worried about how people perceive their appearance. They always assume and think that people are laughing and talking about them because of how they look. They avoid social gatherings, interaction with friends, dating, or places where their body can be seen or exposed such as parties, events, schooling environment, or crowded places such as shopping malls [17]. They think that everyone thinks they are unattractive, and because of that, they avoid any social or leisure activities. In one study, 18% had dropped out of school primarily due to BDD [18], and in another study,

Individual with BDD also have delusional beliefs. They do not recognize that the appearance flaws they perceive are nonexistent [19]. They also tend to think that most people share their views of the supposed defects. People with delusional beliefs also realize that their appearance has a psychological cause; they simply think their beliefs are true [17]. Individuals with BDD display delusion beliefs, believing that people around them notice their defect and evaluate them negatively

*DOI: http://dx.doi.org/10.5772/intechopen.81822*

repetitive and difficult to resist or control the rituals.

**2.2 Ritual**

**of functioning**

**2.4 Other features of BDD**

22% had dropped out of school due to BDD [15].

*2.4.1 Avoidance behaviors*

*2.4.2 Delusional beliefs*

as a consequence of their ugliness.

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder DOI: http://dx.doi.org/10.5772/intechopen.81822*

#### **2.2 Ritual**

*Cognitive Behavioral Therapy - Theories and Applications*

people, perception has been shaped in such a way that it contradicts with reality. One of the most common forms of this disorder is body dysmorphic disorder (BDD). BDD is a severe disorder defined by a preoccupation with perceived imperfections in appearance and resulting in repetitive behaviors, which also causes a clinically significant distress or functional impairment [3]. BDD also has a high rate of suicidality [4, 5]. BDD typically begins during early adolescence and appears to be common in adults. BDD, previously known as dysmorphobia, represents a psychotic delusional state, whereby the individual was unable to realize, even for a fleeting moment, that their ideas were irrational. Individuals with BDD believe they looked ugly or unattractive when in reality they look normal and attractive. Many people with BDD will seek unnecessary dermatologic, dental, and other cosmetic treatments in hopes of removing their negative perceptions on physical appearance. These procedures have poor outcomes and lead to individuals distress, often worsening the symptoms and leading to the dissatisfaction and loss of self-esteem [6]. Feelings of frustration, hopelessness, or shame resulting from engagement in or disturbance of rituals can

also lead to anger outbursts and may involve physical aggression [7].

The diagnostic criteria of BDD are as follows:

exercise extremely that in turn leads to bodily damage [3].

**2.1 Appearance preoccupation**

**2. Diagnosis and clinical assessment of body dysmorphic disorder**

Previously, BDD was considered a somatoform disorder because its central feature is a psychological preoccupation with somatic issues. However, increasing evidence has indicated it was more closely related to obsessive-compulsive disorder (OCD), accounting for its relocation to the obsessive-compulsive and related disorders section in the *Diagnostic and Statistical Manual of Mental Disorders-5* [3].

Individuals with BDD are constantly preoccupied and persistently complaining about their appearance which they deem horrible and intrusive [8]. Individuals with BDD exhibit perfectionistic thinking and maladaptive attractiveness beliefs [9]. The average number of body areas that is of a concern to these individuals was five to seven, and preoccupation may focus on any areas of the body and commonly involves the face, nose, hair, skin, breast, teeth, and others [3]. However, some can concern only one area. Concerns range from looking unattractive to looking disgusting. These thoughts are very distressing and are associated with a feeling of low self-esteem, rejection sensitivity, embarrassment, and shame [10]. Generally, they spend at least an hour a day of thinking about the supposed appearance flaws. On average, they will spend between 3 and 8 hours a day on this [10]. Some individuals are also concerned about the perceived asymmetry of body areas. A study showed that females with BDD were more likely to be preoccupied with their hips, weight, breasts, legs, pick their skin and disguise with makeup, while males with BDD were more likely to be preoccupied with their body build, genitals, and hair thinning [11, 12]. Muscle dysmorphia, a form of BDD occurring mostly in male individuals, consists of preoccupation with the idea that one's body is too small or insufficiently lean or insufficiently muscular. In reality, these individuals actually have a normal-looking body and are muscular. Some are also very preoccupied with other areas such as their hair and skin. A majority of them also practices diet and

**46**

Individuals with BDD also perform ritual behavior by mirror checking or compensating in attempts to alleviate their concerns and anxiety. Excessive grooming, camouflaging, and skin picking are also common in BDD [8, 13]. Some individuals are excessively tan, for example, to darken "pale" skin or diminish perceived acne. In addition, some individuals repeatedly change their clothes such as to camouflage the perceived defects, or some individuals compulsively shop for their beauty products [3]. Many of these behaviors are considered compulsive, in that they are repetitive and difficult to resist or control the rituals.

#### **2.3 Distress or impairment in social, occupational, or other important areas of functioning**

People with BDD also have the idea of reference which means they think everything that goes on in their world is related to them. This thinking and perception can cause disruption in their lives. Impairment in functioning can include problems with any aspect of social functioning that is caused by BDD, such as problems with relationships, socializing, intimacy, or difficulty being around other people. It also includes problems with the ability to function in a job, academically, or in one's role in life [14].

Among adults, BDD results in high rates of occupational impairment, unemployment, social dysfunction, and social isolation [15]. Similarly, BDD in youths is associated with major functional impairment, including reduced academic performance, social withdrawal, and dropping out of school [16]. They may even become housebound [8]. Overall, individuals with BDD have a markedly poor quality of life.

#### **2.4 Other features of BDD**

#### *2.4.1 Avoidance behaviors*

Individuals with BDD also avoid some social situations because they feel ashamed and embarrassed about their appearance. They are also concerned and worried about how people perceive their appearance. They always assume and think that people are laughing and talking about them because of how they look. They avoid social gatherings, interaction with friends, dating, or places where their body can be seen or exposed such as parties, events, schooling environment, or crowded places such as shopping malls [17]. They think that everyone thinks they are unattractive, and because of that, they avoid any social or leisure activities. In one study, 18% had dropped out of school primarily due to BDD [18], and in another study, 22% had dropped out of school due to BDD [15].

#### *2.4.2 Delusional beliefs*

Individual with BDD also have delusional beliefs. They do not recognize that the appearance flaws they perceive are nonexistent [19]. They also tend to think that most people share their views of the supposed defects. People with delusional beliefs also realize that their appearance has a psychological cause; they simply think their beliefs are true [17]. Individuals with BDD display delusion beliefs, believing that people around them notice their defect and evaluate them negatively as a consequence of their ugliness.

Individuals with BDD who have delusional beliefs are also difficult to treat. Research done by other researchers has shown that 79% of patients have had ideas or delusions of reference, believing that others take special notice of the perceived defects [15, 18].

#### *2.4.3 Skin picking*

Individuals with BDD also compulsively pick their skin to try to remove any imperfections in their body. They may use their fingers or other tools such as needles, knives, razors, pins, and other sharp objects that can harm their skin. This ritualistic behavior can take hours a day and can cause tissue damage. However, they have no intention of damaging their skin, but they have difficulties in trying to control the ritualistic behavior [17].

#### **3. Body dysmorphic disorder and other mental illnesses**

Individual who meet the diagnostic criteria for BDD will often also develop other mental illnesses. BDD is also associated with eating disorder, anxiety disorder, major depression disorder (MDD), substance use disorder, social phobia, obsessivecompulsive disorder (OCD), panic disorder, and post-traumatic stress disorder [8, 10, 20, 21]. Among BDD sufferers, 94% reported that they felt depressed at some point due to their illness [10]. In the largest comorbidity study (n = 293), the most common disorders were MDD (lifetime prevalence of 76%), social anxiety disorder (37%), and OCD (32%) [21].

OCD and social phobia have also been found to have a high lifetime prevalence in BDD individual of 32–33% and 37–39%, respectively. About 10–15% of those with BDD have a lifetime history of anorexia nervosa or bulimia nervosa. Moreover, 2–7% of BDD have a history of somatoform disorder [8, 21, 22].

Meanwhile, 60% of subjects in one study reported that their substance use began after symptoms of BDD and 68% reported that their illness contributed to their substance use becoming problematic [23, 24]. Among individual with BDD, 42.6% reported an alcohol use disorder, and 30.1% reported a cannabis use disorder [23, 24]. Muscle dysmorphia, a specific type of BDD, was also found to have the highest rates of substance abuse such as street drugs and alcohol at the rate of 86% [10]. Moreover, 68% of individuals with a lifetime substance use disorder reported that BDD contributed to their substance use disorder [23]. On the other hand, studies suggest that certain psychoactive drugs, such as cocaine or methamphetamine, may worsen obsession symptoms [25].

Besides the comorbidity, BDD is also associated with increased suicidal ideation. The extant literature suggests a particularly strong link between BDD and elevated rates of suicidal thoughts and suicidal behaviors. Up to 75% of individuals with BDD report experiencing lifetime suicidal ideation, and 25% of individual with BDD report a history of making a suicide attempt. The data suggest a rate of completed suicide up to 45 times that of the general population [26]. The delusional variant of BDD is considered more severe and leads to suicide [27, 28]. BDD appears to engender the four psychological constructs thought to predict suicide: perceived burdensomeness, thwarted belongingness, low fear of death, and high physical pain tolerance [29].

The other researcher also stated that physically painful BDD behaviors that involved cosmetic surgery and restrictive eating would be associated with suicide attempts but not suicide-related ideation because these behaviors increase capability for, but not thoughts about, suicide [29].

**49**

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder*

interpretations because this happens automatically to them [17].

predisposed beliefs they learned previously [17].

attention to perceived flaws.

such as appearance flaws [33].

**4. Cognitive behavioral model for understanding body dysmorphic** 

Few researchers have contributed to a cognitive behavioral model for understanding BDD [30, 31]. According to this model, an individual's behavior and emotions are thought to be determined by their interpretation of events. It is not the incidents or events that determine what the individual feels but of how he or she perceives it. However, many people always accept their perceptions of situations or events as true and may even be unaware that they are making these negative

According to Beck, the foundation of cognitive behavioral is that individuals develop an understanding about themselves, other people, and their personal worlds. Core beliefs are central ideas about the self and others [32]. Individuals with BDD usually have negative core beliefs relating to their personal worthwhile underlying their negative view of appearance [17]. They always overestimate the meaning and importance of perceived imperfections and misinterpret them as major personal flaws. An example of core beliefs about themselves is "If I am ugly, everyone will not love me and I will be isolated" or "I am worthless." They interpret minor imperfections in appearance as a signal of major flaws because they hold

Besides having personal negative core beliefs about themselves, individual with BDD always has a negative core belief about others around them such as thinking "people only like sexy body." This leads to their core beliefs and assumptions that they are unattractive and worthless. They tend to jump to conclusions without considering any explanations for their negative interpretation of situations [17]. Perceived imperfections of their negative interpretations will lead to negative emotions, such as anxiety, shame, and sadness, which further increase selective

As a way of reducing their anxiety, shame, or sadness, individuals with BDD will engage in ritual behavior or avoidance of social situations. Avoidance behavior includes avoiding social contact and other situations such as going to school or parties. Meanwhile, ritual behaviors include mirror checking, skin picking, reassurance seeking, repeated plastic surgery, and excessive grooming situations [17]. Since the rituals and avoidance behaviors can temporarily reduce negative emotions, they are negatively reinforced and, in this way, are hypothesized to maintain dysfunctional BDD-related beliefs. Therefore, cognitive behavioral therapy (CBT) for BDD targets cognitive, emotional, and behavioral factors and generally includes psychoeducation, cognitive intervention, exposure to avoided situations, and prevention of rituals and perceptual retraining such as to reduce selective attention to details

The model of BDD from the other researcher focuses on the experience of people with BDD when they are alone [34]. The model begins with the trigger of an external representation of the individual's body image, typically in front of a mirror. The process of selective attention begins by focusing on specific aspects of the external representation, which leads to a heightened awareness and relative exaggeration of certain features. As a result of this process, the person with BDD constructs a distorted mental representation of their body image. Mirror gazing activates idealized values about the importance of appearance and, in some individual with BDD, values about perfectionism or symmetry and thinking of the self as an esthetic object. This leads to a negative esthetic appraisal and comparisons of three different images—the external representation (usually in a mirror), the ideal body image, and the distorted body image. These repeated comparisons leave them uncertain about their appearance,

*DOI: http://dx.doi.org/10.5772/intechopen.81822*

**disorder (BDD)**

#### **4. Cognitive behavioral model for understanding body dysmorphic disorder (BDD)**

Few researchers have contributed to a cognitive behavioral model for understanding BDD [30, 31]. According to this model, an individual's behavior and emotions are thought to be determined by their interpretation of events. It is not the incidents or events that determine what the individual feels but of how he or she perceives it. However, many people always accept their perceptions of situations or events as true and may even be unaware that they are making these negative interpretations because this happens automatically to them [17].

According to Beck, the foundation of cognitive behavioral is that individuals develop an understanding about themselves, other people, and their personal worlds. Core beliefs are central ideas about the self and others [32]. Individuals with BDD usually have negative core beliefs relating to their personal worthwhile underlying their negative view of appearance [17]. They always overestimate the meaning and importance of perceived imperfections and misinterpret them as major personal flaws. An example of core beliefs about themselves is "If I am ugly, everyone will not love me and I will be isolated" or "I am worthless." They interpret minor imperfections in appearance as a signal of major flaws because they hold predisposed beliefs they learned previously [17].

Besides having personal negative core beliefs about themselves, individual with BDD always has a negative core belief about others around them such as thinking "people only like sexy body." This leads to their core beliefs and assumptions that they are unattractive and worthless. They tend to jump to conclusions without considering any explanations for their negative interpretation of situations [17]. Perceived imperfections of their negative interpretations will lead to negative emotions, such as anxiety, shame, and sadness, which further increase selective attention to perceived flaws.

As a way of reducing their anxiety, shame, or sadness, individuals with BDD will engage in ritual behavior or avoidance of social situations. Avoidance behavior includes avoiding social contact and other situations such as going to school or parties. Meanwhile, ritual behaviors include mirror checking, skin picking, reassurance seeking, repeated plastic surgery, and excessive grooming situations [17]. Since the rituals and avoidance behaviors can temporarily reduce negative emotions, they are negatively reinforced and, in this way, are hypothesized to maintain dysfunctional BDD-related beliefs. Therefore, cognitive behavioral therapy (CBT) for BDD targets cognitive, emotional, and behavioral factors and generally includes psychoeducation, cognitive intervention, exposure to avoided situations, and prevention of rituals and perceptual retraining such as to reduce selective attention to details such as appearance flaws [33].

The model of BDD from the other researcher focuses on the experience of people with BDD when they are alone [34]. The model begins with the trigger of an external representation of the individual's body image, typically in front of a mirror. The process of selective attention begins by focusing on specific aspects of the external representation, which leads to a heightened awareness and relative exaggeration of certain features. As a result of this process, the person with BDD constructs a distorted mental representation of their body image. Mirror gazing activates idealized values about the importance of appearance and, in some individual with BDD, values about perfectionism or symmetry and thinking of the self as an esthetic object. This leads to a negative esthetic appraisal and comparisons of three different images—the external representation (usually in a mirror), the ideal body image, and the distorted body image. These repeated comparisons leave them uncertain about their appearance,

*Cognitive Behavioral Therapy - Theories and Applications*

defects [15, 18].

*2.4.3 Skin picking*

control the ritualistic behavior [17].

disorder (37%), and OCD (32%) [21].

may worsen obsession symptoms [25].

ity for, but not thoughts about, suicide [29].

Individuals with BDD who have delusional beliefs are also difficult to treat. Research done by other researchers has shown that 79% of patients have had ideas or delusions of reference, believing that others take special notice of the perceived

Individuals with BDD also compulsively pick their skin to try to remove any imperfections in their body. They may use their fingers or other tools such as needles, knives, razors, pins, and other sharp objects that can harm their skin. This ritualistic behavior can take hours a day and can cause tissue damage. However, they have no intention of damaging their skin, but they have difficulties in trying to

Individual who meet the diagnostic criteria for BDD will often also develop other mental illnesses. BDD is also associated with eating disorder, anxiety disorder, major depression disorder (MDD), substance use disorder, social phobia, obsessivecompulsive disorder (OCD), panic disorder, and post-traumatic stress disorder [8, 10, 20, 21]. Among BDD sufferers, 94% reported that they felt depressed at some point due to their illness [10]. In the largest comorbidity study (n = 293), the most common disorders were MDD (lifetime prevalence of 76%), social anxiety

OCD and social phobia have also been found to have a high lifetime prevalence in BDD individual of 32–33% and 37–39%, respectively. About 10–15% of those with BDD have a lifetime history of anorexia nervosa or bulimia nervosa. Moreover,

Meanwhile, 60% of subjects in one study reported that their substance use began after symptoms of BDD and 68% reported that their illness contributed to their substance use becoming problematic [23, 24]. Among individual with BDD, 42.6% reported an alcohol use disorder, and 30.1% reported a cannabis use disorder [23, 24]. Muscle dysmorphia, a specific type of BDD, was also found to have the highest rates of substance abuse such as street drugs and alcohol at the rate of 86% [10]. Moreover, 68% of individuals with a lifetime substance use disorder reported that BDD contributed to their substance use disorder [23]. On the other hand, studies suggest that certain psychoactive drugs, such as cocaine or methamphetamine,

Besides the comorbidity, BDD is also associated with increased suicidal ideation. The extant literature suggests a particularly strong link between BDD and elevated rates of suicidal thoughts and suicidal behaviors. Up to 75% of individuals with BDD report experiencing lifetime suicidal ideation, and 25% of individual with BDD report a history of making a suicide attempt. The data suggest a rate of completed suicide up to 45 times that of the general population [26]. The delusional variant of BDD is considered more severe and leads to suicide [27, 28]. BDD appears to engender the four psychological constructs thought to predict suicide: perceived burdensomeness, thwarted belongingness, low fear of death, and high physical pain tolerance [29]. The other researcher also stated that physically painful BDD behaviors that involved cosmetic surgery and restrictive eating would be associated with suicide attempts but not suicide-related ideation because these behaviors increase capabil-

**3. Body dysmorphic disorder and other mental illnesses**

2–7% of BDD have a history of somatoform disorder [8, 21, 22].

**48**

which encourages for further mirror gazing. The individual with BDD desire to see exactly how he or she looks is only rewarded by looking in the mirror. However, the longer the person looks, the worse they feel and the more the belief of ugliness and unattractiveness is reinforced. When not looking in a mirror, the individual may focus and give more attention to his or her internal body image and ruminate on its ugliness. There is often a marked discrepancy between the actual and the ideal body images, and this inevitably leads to a depressed mood and negative thoughts [34].

#### **5. The development of body dysmorphic disorder**

An understanding of how BDD develops is still uncertain, and studies about this are still restricted compared to other disorders. However, there are several key factors that play a role in the development of BDD such as serotonin hypothesis and other neurotransmitters, abnormalities in the brain, culture and mass media roles, parenting styles, environment, and genetic predispositions that contribute to BDD.

#### **5.1 The serotonin hypothesis and other neurotransmitters**

Individuals with BDD may have imbalance in the brain's chemical serotonin. In support of this theory, BDD often improves with serotonin reuptake inhibitor medications, which help to boost serotonin in the brain to a healthy level. The brain consists of billions of nerve cells and serotonin. Serotonin, one of the neurotransmitters, is a natural brain chemical that carries information from nerve cell to nerve cell. Serotonin permits cells to communicate with one another and to function [10].

Serotonin is especially abundant in certain parts of the brain that may be especially important in BDD. It is critical to many bodily functions including mood, memory, cognition, appetite, eating behavior, sleep, sexual behavior, and pain. It restrains aggressive and destructive behaviors. Serotonin is involved in a variety of disorders such as OCD and depression. Serotonin is also involved in the visual system and visual processing, and it may help protect animals from overreacting to unimportant sensory input from the environment. This is interesting given that people with BDD appear to overfocus on unimportant details of appearance and "overreact" to nonexistent threats. Serotonin reuptake inhibitor medication helps people become less "overreactive" and less focused on minor appearance flaws. In addition to possible effects on the visual system, serotonin reuptake inhibitors might alleviate BDD symptoms by increasing serotonin release in the striatum and other key brain areas and by inhibiting an overactive amygdala [10]. It is likely that other neurotransmitters are also involved in BDD. For example, dopamine, which may, in combination with serotonin, be particularly important in the development delusional form of BDD [10].

#### **5.2 Abnormalities in the brain**

BDD highly likely involves a complex interplay of dysfunction in several neural regions and systems of the brain. Left-sided prefrontal and temporal regions involved in visual processing of faces, and amygdala hyperreactivity, may play a role in development of BDD [10]. Dysfunction in frontal-striatal brain circuits may also be involved. A study conducted by researchers which compared women with BDD to healthy women without BDD using MRI scans to visualize the brain's structure. The researchers found that the BDD group's MRI scans differed in subtle ways from healthy woman. There were differences in the caudate, a C-shaped structure deep in the brain's core (the striatum), which regulates voluntary movements, habits, learning, and cognitions and may be linked to repetitive or ritual behaviors in BDD [10].

**51**

**5.3 Genetic**

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder*

as well as the parietal lobe can impair perception of bodies and faces [10].

thought patterns and urges to perform compulsive behaviors [35].

Moreover, one study from the Department of Psychiatry and Biobehavioral Sciences, which studied the abnormalities of visual processing and frontostriatal systems in body dysmorphic disorder, found out that individuals with BDD also demonstrated visual processing and frontostriatal abnormalities when viewing their own face. Moreover, brain activity in these systems correlates with symptom severity. The frontostriatal system findings, especially *orbitofrontal cortex* (OFC) and caudate hyperactivity, suggest possible similar neural pathophysiology to obsessive–compulsive disorder. Abnormalities in visual processing systems may contribute distorted perceptual input to frontostriatal systems, which may be associated with the experience of aversion and that may subsequently mediate obsessive

A study also discovers that orbitofrontal cortex and anterior cingulate cortex volumes of individual with BDD were significantly smaller than healthy individuals. The individual with BDD brain has more white substances than the healthy individuals [10, 36]. There is also a tendency of an increase of thalamic volume in individual with BDD compared with healthy individual. Evidence also found that right amygdala volume has shown a significant correlation with BDD symptom severity, which suggests a different lateral involvement of the brain regions [37].

There have been small studies investigating genetic factors underlying BDD. Nevertheless, heredity and genetic factors do appear to contribute to BDD. Having certain genes will increase the chances of having certain personality traits, where certain brain circuits are hyperreactive and other characteristics may further increase the risk of getting BDD. Research studies also found that about 20% of people with BDD have at least one first-degree relative such as parent, sibling, or child with BDD. About 6% of all first-degree relatives have BDD. This rate is an estimated three to six times higher than in the general population [10]. BDD probably runs in families because family members share genes that increase the risk of getting BDD. In addition, a preliminary genetics study by researchers found that a certain form of a gene called the GABAA-γ2 receptor gene was more common in

Moreover, 8% of individuals with BDD have a family member also diagnosed with BDD, a statistic four to eight times prevalent in the general population [38]. Some studies show that BDD is more common in individual whose blood relatives also have this condition or obsessive-compulsive disorder [39]. The association between body dysmorphic symptoms and obsessive-compulsive symptoms is largely explained by shared genetic factors. Environmental risk factors were largely unique to each phenotype. These results also support current recommendations to group BDD together with OCD in the same *DSM-5*, although comparison with other phenotypes such as somatoform disorders and social phobia is needed [39]. In addition, the results of twin studies indicate that genetic factors account for approximately 42–44% of the variance in BDD-like symptoms, with the remaining variance being account for by non-shared environmental influences [40, 41].

people with BDD than in those without BDD [10].

Other brain regions might also be involved in BDD. A small neuroimaging study that used single photon emission computed tomography (SPECT) showed various areas of hyperactivation in diffused areas of the brain such as the frontal, temporal, occipital, and parietal lobes [10]. Possible that all of these areas may be involved, it makes sense that the fusiform face and extrastriate body areas, in particular, which are located in the temporal/occipital area, are important in the perception of the body image, and facial emotion perception might play a role. Damage to these areas

*DOI: http://dx.doi.org/10.5772/intechopen.81822*

#### *A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder DOI: http://dx.doi.org/10.5772/intechopen.81822*

Other brain regions might also be involved in BDD. A small neuroimaging study that used single photon emission computed tomography (SPECT) showed various areas of hyperactivation in diffused areas of the brain such as the frontal, temporal, occipital, and parietal lobes [10]. Possible that all of these areas may be involved, it makes sense that the fusiform face and extrastriate body areas, in particular, which are located in the temporal/occipital area, are important in the perception of the body image, and facial emotion perception might play a role. Damage to these areas as well as the parietal lobe can impair perception of bodies and faces [10].

Moreover, one study from the Department of Psychiatry and Biobehavioral Sciences, which studied the abnormalities of visual processing and frontostriatal systems in body dysmorphic disorder, found out that individuals with BDD also demonstrated visual processing and frontostriatal abnormalities when viewing their own face. Moreover, brain activity in these systems correlates with symptom severity. The frontostriatal system findings, especially *orbitofrontal cortex* (OFC) and caudate hyperactivity, suggest possible similar neural pathophysiology to obsessive–compulsive disorder. Abnormalities in visual processing systems may contribute distorted perceptual input to frontostriatal systems, which may be associated with the experience of aversion and that may subsequently mediate obsessive thought patterns and urges to perform compulsive behaviors [35].

A study also discovers that orbitofrontal cortex and anterior cingulate cortex volumes of individual with BDD were significantly smaller than healthy individuals. The individual with BDD brain has more white substances than the healthy individuals [10, 36]. There is also a tendency of an increase of thalamic volume in individual with BDD compared with healthy individual. Evidence also found that right amygdala volume has shown a significant correlation with BDD symptom severity, which suggests a different lateral involvement of the brain regions [37].

#### **5.3 Genetic**

*Cognitive Behavioral Therapy - Theories and Applications*

which encourages for further mirror gazing. The individual with BDD desire to see exactly how he or she looks is only rewarded by looking in the mirror. However, the longer the person looks, the worse they feel and the more the belief of ugliness and unattractiveness is reinforced. When not looking in a mirror, the individual may focus and give more attention to his or her internal body image and ruminate on its ugliness. There is often a marked discrepancy between the actual and the ideal body images,

An understanding of how BDD develops is still uncertain, and studies about this are still restricted compared to other disorders. However, there are several key factors that play a role in the development of BDD such as serotonin hypothesis and other neurotransmitters, abnormalities in the brain, culture and mass media roles, parenting styles, environment, and genetic predispositions that contribute to BDD.

Individuals with BDD may have imbalance in the brain's chemical serotonin. In support of this theory, BDD often improves with serotonin reuptake inhibitor medications, which help to boost serotonin in the brain to a healthy level. The brain consists of billions of nerve cells and serotonin. Serotonin, one of the neurotransmitters, is a natural brain chemical that carries information from nerve cell to nerve cell. Serotonin permits cells to communicate with one another and to function [10]. Serotonin is especially abundant in certain parts of the brain that may be especially important in BDD. It is critical to many bodily functions including mood, memory, cognition, appetite, eating behavior, sleep, sexual behavior, and pain. It restrains aggressive and destructive behaviors. Serotonin is involved in a variety of disorders such as OCD and depression. Serotonin is also involved in the visual system and visual processing, and it may help protect animals from overreacting to unimportant sensory input from the environment. This is interesting given that people with BDD appear to overfocus on unimportant details of appearance and "overreact" to nonexistent threats. Serotonin reuptake inhibitor medication helps people become less "overreactive" and less focused on minor appearance flaws. In addition to possible effects on the visual system, serotonin reuptake inhibitors might alleviate BDD symptoms by increasing serotonin release in the striatum and other key brain areas and by inhibiting an overactive amygdala [10]. It is likely that other neurotransmitters are also involved in BDD. For example, dopamine, which may, in combination with serotonin, be particularly important in the development delusional form of BDD [10].

BDD highly likely involves a complex interplay of dysfunction in several neural

involved in visual processing of faces, and amygdala hyperreactivity, may play a role in development of BDD [10]. Dysfunction in frontal-striatal brain circuits may also be involved. A study conducted by researchers which compared women with BDD to healthy women without BDD using MRI scans to visualize the brain's structure. The researchers found that the BDD group's MRI scans differed in subtle ways from healthy woman. There were differences in the caudate, a C-shaped structure deep in the brain's core (the striatum), which regulates voluntary movements, habits, learning, and cognitions and may be linked to repetitive or ritual behaviors in BDD [10].

regions and systems of the brain. Left-sided prefrontal and temporal regions

and this inevitably leads to a depressed mood and negative thoughts [34].

**5. The development of body dysmorphic disorder**

**5.1 The serotonin hypothesis and other neurotransmitters**

**50**

**5.2 Abnormalities in the brain**

There have been small studies investigating genetic factors underlying BDD. Nevertheless, heredity and genetic factors do appear to contribute to BDD. Having certain genes will increase the chances of having certain personality traits, where certain brain circuits are hyperreactive and other characteristics may further increase the risk of getting BDD. Research studies also found that about 20% of people with BDD have at least one first-degree relative such as parent, sibling, or child with BDD. About 6% of all first-degree relatives have BDD. This rate is an estimated three to six times higher than in the general population [10]. BDD probably runs in families because family members share genes that increase the risk of getting BDD. In addition, a preliminary genetics study by researchers found that a certain form of a gene called the GABAA-γ2 receptor gene was more common in people with BDD than in those without BDD [10].

Moreover, 8% of individuals with BDD have a family member also diagnosed with BDD, a statistic four to eight times prevalent in the general population [38]. Some studies show that BDD is more common in individual whose blood relatives also have this condition or obsessive-compulsive disorder [39]. The association between body dysmorphic symptoms and obsessive-compulsive symptoms is largely explained by shared genetic factors. Environmental risk factors were largely unique to each phenotype. These results also support current recommendations to group BDD together with OCD in the same *DSM-5*, although comparison with other phenotypes such as somatoform disorders and social phobia is needed [39].

In addition, the results of twin studies indicate that genetic factors account for approximately 42–44% of the variance in BDD-like symptoms, with the remaining variance being account for by non-shared environmental influences [40, 41].

A twin study in females that operate self-report measures of dysmorphic concerns and concerns about body odor and body malfunction from the United Kingdom twin registry found that genetic factors accounted for approximately 44% of the variance of dysmorphic concerns [40].

#### **5.4 Cultural factors**

There are studies that have examined the role of culture in the development of BDD. The tendency to link body attractiveness with positive personal qualities has become a cultural stereotype in the world. Because of the stereotype, people start to be concerned and anxious about their looks and appearance although they are normal with no defects. They exaggerated worry about what other people say about their appearance.

BDD is not specific to one country or culture. Furthermore, cases of BDD have been reported in a variety of countries, including the United States, Canada, Europe, China, Japan, and Africa [27, 42–44]. In Japan, for example, it is called shubo kyofu. Shubo kyofu is characterized by excessive fear of having bodily deformity, and it is similar with BDD. According to the traditional Japanese diagnostic system, shubo kyofu is a subtype of taijin kyofusho (social anxiety), a cultural syndrome characterized by fear and avoidance of interpersonal relationship [45].

In Korea, females typically more prefer slim and skinny bodies. Even though they are normal or underweight, they strive for weight control routinely. Severely losing weight for women has become a social problem due to the appearanceoriented trend in Japan. A study conducted by researchers from the Department of Dental Hygiene, Kangwon University, was performed by 200 health-related and 200 health-unrelated college students, respectively, at K College in Gangwon province. The study showed that as a result of analyzing the relationship between the BMI of the female students and their dissatisfied parts of the body, overweight female students were more dissatisfied with the entire lower parts of their body and whole body, and the female students of normal weight were more dissatisfied with their waist and belly than the other groups. The underweight female students were more dissatisfied with their chests and breasts. But there were no differences in the way they wanted to try and change dissatisfied parts of the body [46].

Meanwhile, a group of researchers from Brazil did a study in Abdominal Plastic Surgery Unit of the São Paulo Hospital, Brazil. A high prevalence of BDD symptoms was found among candidates for abdominoplasty and body weight, and shape concerns were significantly associated with severity of BDD symptoms. It was found that the more severe the symptoms of BDD, the higher the level of concern with body weight and shape. Individuals with BDD having distorted self-perception of body shape or distorted comparative perception of body image were, respectively, 3.67 or 5.93 times more likely to show more severe symptoms of BDD than individual with a more accurate perception [47].

To the best of our knowledge, there has not been any published literature on the prevalence of BDD among patients in an Asian population. However, the results coming from the researchers in Singapore hospitals show that BDD is quite prevalent among patients who have received cosmetic rhinoplasty. BDD patients are likely to have poorer subjective outcomes after surgery although they may experience some improvement in satisfaction when compared to before surgery [48].

One study has conducted the only cross-cultural study published to date and found that BDD prevalence rates in BDD are fairly similar between American (N = 101, 4%) and German students (N = 133, 5.3%) [49]. Cultural factors may play a role in which body parts are of a concern and how other BDD symptoms are

**53**

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder*

expressed, as different cultures may have variations in esthetic standards of beauty,

It appears that cultural values and preferences may influence and shape BDD symptoms to some degree. For example, eyelid concerns appear common in Japan but rare in Western countries. Worried about displeasing other people by being unattractive also seems more common in Japan than in the United States. Some people say that their BDD symptoms began when they moved to another culture

Environment and life experiences may contribute to BDD, especially if they involve negative social evaluations about someone's appearance, body or self-image, or even childhood neglect or abuse. Bullying has been shown to be associated with BDD, and most episodes were interpersonal and occurred during grade school or middle school [51]. BDD symptoms were higher when adolescents self-reported more appearance teasing and higher social anxiety. Moreover, it was appearance teasing by cross-sex peers, rather than same-sex peers, that was uniquely associated with elevated BDD symptoms [52]. In longitudinal studies of environmental risk factors in BDD, peer victimization in school students was prospectively associated with the development of BDD in which the symptoms appeared 12 months after incidents and also exacerbated low perceptions of peer acceptance [53]. With that, a conclusion can be made that experiences of bullying may play a causal role in BDD. Moreover, the current results suggest that individuals who experienced physical and sexual assault in early life might be at a higher risk for developing BDD. Studies have shown that adults with BDD reported high levels of childhood maltreatment,

Furthermore, retrospective reported rates of abuse are elevated in people with BDD compared with healthy control. The BDD group reported more retrospective experiences of sexual and physical abuse in childhood or adolescence than did healthy people. This study provides preliminary evidence of the importance of examining abuse as a potential risk factor in the development of BDD [16].

Consistent with the other authors, emotional neglect was the most common form of perceived maltreatment in both males and females. Severity of selfreported abuse and neglect among females with BDD was higher than normal reported for women in health maintenance organization (HMO) sample. Consistent with previous research, females reported greater severity of perceived sexual abuse than males [55, 56]. Self-reported sexual abuse severity was the only type of

Parental communication styles with children also play a role in development of BDD. Individuals with BDD also report that their parents directly or indirectly gave more importance to attractiveness. Their parents are always commenting on various body parts of certain actors or actresses or characteristics of their friends as compared to themselves. It may also be that people with BDD are more prone to recall such information. Mothers' attitude toward their children's body shape will put their children at risk of BDD and eating disorders such as anorexia and bulimia when they communicate their preferred or ideal body shapes to their children through verbal remarks and the control of their child's food intake. Incidentally, this

will shape a negative self-esteem and a sense of low self-worth to the child.

*DOI: http://dx.doi.org/10.5772/intechopen.81822*

**5.5 Environment and life experiences**

with up to 79% of patients reporting abuse [54].

maltreatment related to current BDD severity.

**5.6 Parental styles**

but this has yet to be studied in relation to BDD [50].

and felt that they looked different and did not fit in [10].

#### *A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder DOI: http://dx.doi.org/10.5772/intechopen.81822*

expressed, as different cultures may have variations in esthetic standards of beauty, but this has yet to be studied in relation to BDD [50].

It appears that cultural values and preferences may influence and shape BDD symptoms to some degree. For example, eyelid concerns appear common in Japan but rare in Western countries. Worried about displeasing other people by being unattractive also seems more common in Japan than in the United States. Some people say that their BDD symptoms began when they moved to another culture and felt that they looked different and did not fit in [10].

#### **5.5 Environment and life experiences**

*Cognitive Behavioral Therapy - Theories and Applications*

variance of dysmorphic concerns [40].

**5.4 Cultural factors**

their appearance.

A twin study in females that operate self-report measures of dysmorphic concerns and concerns about body odor and body malfunction from the United Kingdom twin registry found that genetic factors accounted for approximately 44% of the

There are studies that have examined the role of culture in the development of BDD. The tendency to link body attractiveness with positive personal qualities has become a cultural stereotype in the world. Because of the stereotype, people start to be concerned and anxious about their looks and appearance although they are normal with no defects. They exaggerated worry about what other people say about

BDD is not specific to one country or culture. Furthermore, cases of BDD have been reported in a variety of countries, including the United States, Canada, Europe, China, Japan, and Africa [27, 42–44]. In Japan, for example, it is called shubo kyofu. Shubo kyofu is characterized by excessive fear of having bodily deformity, and it is similar with BDD. According to the traditional Japanese diagnostic system, shubo kyofu is a subtype of taijin kyofusho (social anxiety), a cultural syndrome characterized by fear and avoidance of interpersonal relationship [45]. In Korea, females typically more prefer slim and skinny bodies. Even though they are normal or underweight, they strive for weight control routinely. Severely losing weight for women has become a social problem due to the appearanceoriented trend in Japan. A study conducted by researchers from the Department of Dental Hygiene, Kangwon University, was performed by 200 health-related and 200 health-unrelated college students, respectively, at K College in Gangwon province. The study showed that as a result of analyzing the relationship between the BMI of the female students and their dissatisfied parts of the body, overweight female students were more dissatisfied with the entire lower parts of their body and whole body, and the female students of normal weight were more dissatisfied with their waist and belly than the other groups. The underweight female students were more dissatisfied with their chests and breasts. But there were no differences in the

way they wanted to try and change dissatisfied parts of the body [46].

individual with a more accurate perception [47].

Meanwhile, a group of researchers from Brazil did a study in Abdominal Plastic Surgery Unit of the São Paulo Hospital, Brazil. A high prevalence of BDD symptoms was found among candidates for abdominoplasty and body weight, and shape concerns were significantly associated with severity of BDD symptoms. It was found that the more severe the symptoms of BDD, the higher the level of concern with body weight and shape. Individuals with BDD having distorted self-perception of body shape or distorted comparative perception of body image were, respectively, 3.67 or 5.93 times more likely to show more severe symptoms of BDD than

To the best of our knowledge, there has not been any published literature on the prevalence of BDD among patients in an Asian population. However, the results coming from the researchers in Singapore hospitals show that BDD is quite prevalent among patients who have received cosmetic rhinoplasty. BDD patients are likely to have poorer subjective outcomes after surgery although they may experience some improvement in satisfaction when compared to before surgery [48]. One study has conducted the only cross-cultural study published to date and found that BDD prevalence rates in BDD are fairly similar between American (N = 101, 4%) and German students (N = 133, 5.3%) [49]. Cultural factors may play a role in which body parts are of a concern and how other BDD symptoms are

**52**

Environment and life experiences may contribute to BDD, especially if they involve negative social evaluations about someone's appearance, body or self-image, or even childhood neglect or abuse. Bullying has been shown to be associated with BDD, and most episodes were interpersonal and occurred during grade school or middle school [51]. BDD symptoms were higher when adolescents self-reported more appearance teasing and higher social anxiety. Moreover, it was appearance teasing by cross-sex peers, rather than same-sex peers, that was uniquely associated with elevated BDD symptoms [52]. In longitudinal studies of environmental risk factors in BDD, peer victimization in school students was prospectively associated with the development of BDD in which the symptoms appeared 12 months after incidents and also exacerbated low perceptions of peer acceptance [53]. With that, a conclusion can be made that experiences of bullying may play a causal role in BDD.

Moreover, the current results suggest that individuals who experienced physical and sexual assault in early life might be at a higher risk for developing BDD. Studies have shown that adults with BDD reported high levels of childhood maltreatment, with up to 79% of patients reporting abuse [54].

Furthermore, retrospective reported rates of abuse are elevated in people with BDD compared with healthy control. The BDD group reported more retrospective experiences of sexual and physical abuse in childhood or adolescence than did healthy people. This study provides preliminary evidence of the importance of examining abuse as a potential risk factor in the development of BDD [16].

Consistent with the other authors, emotional neglect was the most common form of perceived maltreatment in both males and females. Severity of selfreported abuse and neglect among females with BDD was higher than normal reported for women in health maintenance organization (HMO) sample. Consistent with previous research, females reported greater severity of perceived sexual abuse than males [55, 56]. Self-reported sexual abuse severity was the only type of maltreatment related to current BDD severity.

#### **5.6 Parental styles**

Parental communication styles with children also play a role in development of BDD. Individuals with BDD also report that their parents directly or indirectly gave more importance to attractiveness. Their parents are always commenting on various body parts of certain actors or actresses or characteristics of their friends as compared to themselves. It may also be that people with BDD are more prone to recall such information. Mothers' attitude toward their children's body shape will put their children at risk of BDD and eating disorders such as anorexia and bulimia when they communicate their preferred or ideal body shapes to their children through verbal remarks and the control of their child's food intake. Incidentally, this will shape a negative self-esteem and a sense of low self-worth to the child.

Although there is no current study to evaluate perceived family criticism of appearance, the researchers have conducted a pilot survey of BDD clients which indicates that familiar modeling and values are significant [57].

#### **5.7 Society and media**

Society and media also play an important role in the development of BDD. The media constantly reinforces the importance of appearance, while at the same time, creating unrealistic expectations about beauty. Although a correlation between the media and BDD seems reasonable, reports of BDD date back as far as the 1800s, prior to current media trends and the ideals it helps enforce. Furthermore, many standards of beauty and attractiveness are established before individuals are influenced by the media [58, 59].

Nowadays, media plays an important role in showing beautiful skinny female models and handsome male models with muscles. Children also are exposed to unrealistic body ideals, such as Barbie's impossibly thin, tall, curvy look with big busted shape or Ken's gigantic muscles. Barbie or Ken will be modeled after by children to look beautiful and charming. In extreme cases, this obsession to the models can lead to "Barbie doll syndrome", which individuals strive to shape a body like a Barbie doll. Constantly, watching perfect bodies can feed youth insecurities over attractiveness and weight. This is proven by a study where male and female adults show that being exposed to idealized bodies such as those in the media, increases dissatisfaction with one's own appearance. Research studies stated that our society's focus on appearance is a major cause of their BDD symptoms [10].

#### **6. Cognitive behavioral therapy intervention of body dysmorphic disorder (BDD)**

BDD can become increasingly worse with time if left untreated. Cognitive behavioral therapy (CBT) is the most practiced form of psychotherapy and has been integrated into highly structured package for the intervention of people suffering BDD.

Research has shown that CBT is an effective intervention in treating individuals with BDD [17, 34, 57, 60]. CBT can be conducted by individual session or group therapy session. Findings from the other researcher indicated that individual and group cognitive behavioral therapies are superior to waiting list for the treatment of BDD [61].

However, it is not yet clear how many sessions and at what frequency are most useful for the intervention. Psychosocial intervention studies for BDD have primarily focused on short term (7–30 sessions) of CBT [62]. Other researchers suggest 6 weeks of intervention with 30 sessions [63] and 12 sessions of 1 hour each [30]. The aim of the intervention is in improving the function and quality of life, in addition to alleviating symptoms of preoccupation with an imagined or slight defect in appearances and compulsive behavior [10, 17, 57].

CBT usually begins with psychoeducation explaining about BDD, followed by both cognitive and behavioral techniques. Cognitive strategies focus on identifying maladaptive beliefs, evaluating the accuracy of these beliefs, and helping the individual develop more realistic beliefs [31, 64]. The behavioral interventions typically consists of exposure and response prevention, which involve gradually confronting the individual with anxiety-provoking situations and asking him or her to stay in that situation without engaging in any rituals or avoidance behaviors until the anxiety decreases on its own. Often, the final session focuses on relapse prevention [63, 65].

**55**

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder*

Intervention for BDD typically begins with giving psychoeducation about the disorder. Psychoeducation refers to the process of providing education and information to those seeking for mental health services, and it is also provided to their family members. Therapists work collaboratively with the clients. The goal of psychoeducation is to help people with BDD to better understand with their mental

Based on the assessment, the therapist focuses on educating the individual about BDD; features of BDD; body areas of concern; the CBT model of BDD; the differences between body image and appearance; BDD and cosmetic surgery; possible causes of BDD, including biological, sociocultural, and psychological factors; and also what treatments will be involved. This is important for their knowledge and view about BDD. Individuals with BDD also need to observe their behavior over time and situations to see what is working and where he or she needs improvement. Consequently, they can brainstorm and try out potential alternative behaviors. It is important to explore factors in the client's current life that are serving to maintain body image concerns, including triggers for negative thoughts about their appearance, interpretations of their thoughts, emotional reactions, and maladap-

In cognitive restructuring techniques, the therapist challenges clients' distorted

Clients will be given homework for every session if necessary, and homework will be discussed in early sessions. For example, they were assigned to record the triggers, excessive thinking, and ritual behavior every time when the symptoms appeared. The aim of the thought record homework is to help client to step back from some of their thoughts and reflect on them. In addition, to help them monitor the negative thoughts that link to the repetitive behavior and help them to be aware

A form of cognitive behavioral therapy intervention emphasizing exposure and response prevention has been shown to produce marked improvement in 50–80% of treated clients [68]. Exposure and response prevention is a process whereby the rituals are actively prevented and the clients are systematically and gradually

beliefs about their physical appearance by encouraging them to evaluate their beliefs in the light of evidence. Cognitive techniques included identifying their maladaptive thoughts, completing thought records, identifying cognitive errors, applying the downward arrow technique, and self-talk that leads up to rituals and blocks them from engaging in social activities like going out with groups of friends, going to parties, or dating. Therapists will introduce clients to common cognitive errors in BDD, for example, "This scar makes me very disgusting." Clients are then encouraged to monitor their appearance-based thoughts in and outside of the session and identify their cognitive errors, for example, "Why am I nervous about going to the party?" After the client has gained skills in identifying their maladaptive thoughts and cognitive errors, the therapist starts to evaluate thoughts with the clients [17, 66]. Cognitive restructuring entails evaluating maladaptive thoughts with Socratic questioning and identifying cognitive errors with the goal of develop-

*DOI: http://dx.doi.org/10.5772/intechopen.81822*

**6.1 Psychoeducation**

health conditions.

tive of coping strategies [17].

**6.2 Cognitive restructuring**

ing more accurate and helpful beliefs [67].

**6.3 Exposure and ritual prevention (ERP)**

exposed to their feared thoughts or situations [69].

of when the trigger comes up.

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder DOI: http://dx.doi.org/10.5772/intechopen.81822*

#### **6.1 Psychoeducation**

*Cognitive Behavioral Therapy - Theories and Applications*

**5.7 Society and media**

enced by the media [58, 59].

**disorder (BDD)**

BDD.

indicates that familiar modeling and values are significant [57].

focus on appearance is a major cause of their BDD symptoms [10].

**6. Cognitive behavioral therapy intervention of body dysmorphic** 

behavioral therapies are superior to waiting list for the treatment of BDD [61].

appearances and compulsive behavior [10, 17, 57].

BDD can become increasingly worse with time if left untreated. Cognitive behavioral therapy (CBT) is the most practiced form of psychotherapy and has been integrated into highly structured package for the intervention of people suffering

Research has shown that CBT is an effective intervention in treating individuals with BDD [17, 34, 57, 60]. CBT can be conducted by individual session or group therapy session. Findings from the other researcher indicated that individual and group cognitive

However, it is not yet clear how many sessions and at what frequency are most useful for the intervention. Psychosocial intervention studies for BDD have primarily focused on short term (7–30 sessions) of CBT [62]. Other researchers suggest 6 weeks of intervention with 30 sessions [63] and 12 sessions of 1 hour each [30]. The aim of the intervention is in improving the function and quality of life, in addition to alleviating symptoms of preoccupation with an imagined or slight defect in

CBT usually begins with psychoeducation explaining about BDD, followed by both cognitive and behavioral techniques. Cognitive strategies focus on identifying maladaptive beliefs, evaluating the accuracy of these beliefs, and helping the individual develop more realistic beliefs [31, 64]. The behavioral interventions typically consists of exposure and response prevention, which involve gradually confronting the individual with anxiety-provoking situations and asking him or her to stay in that situation without engaging in any rituals or avoidance behaviors until the anxiety decreases on its own. Often, the final session focuses on relapse

Although there is no current study to evaluate perceived family criticism of appearance, the researchers have conducted a pilot survey of BDD clients which

Society and media also play an important role in the development of BDD. The media constantly reinforces the importance of appearance, while at the same time, creating unrealistic expectations about beauty. Although a correlation between the media and BDD seems reasonable, reports of BDD date back as far as the 1800s, prior to current media trends and the ideals it helps enforce. Furthermore, many standards of beauty and attractiveness are established before individuals are influ-

Nowadays, media plays an important role in showing beautiful skinny female models and handsome male models with muscles. Children also are exposed to unrealistic body ideals, such as Barbie's impossibly thin, tall, curvy look with big busted shape or Ken's gigantic muscles. Barbie or Ken will be modeled after by children to look beautiful and charming. In extreme cases, this obsession to the models can lead to "Barbie doll syndrome", which individuals strive to shape a body like a Barbie doll. Constantly, watching perfect bodies can feed youth insecurities over attractiveness and weight. This is proven by a study where male and female adults show that being exposed to idealized bodies such as those in the media, increases dissatisfaction with one's own appearance. Research studies stated that our society's

**54**

prevention [63, 65].

Intervention for BDD typically begins with giving psychoeducation about the disorder. Psychoeducation refers to the process of providing education and information to those seeking for mental health services, and it is also provided to their family members. Therapists work collaboratively with the clients. The goal of psychoeducation is to help people with BDD to better understand with their mental health conditions.

Based on the assessment, the therapist focuses on educating the individual about BDD; features of BDD; body areas of concern; the CBT model of BDD; the differences between body image and appearance; BDD and cosmetic surgery; possible causes of BDD, including biological, sociocultural, and psychological factors; and also what treatments will be involved. This is important for their knowledge and view about BDD. Individuals with BDD also need to observe their behavior over time and situations to see what is working and where he or she needs improvement. Consequently, they can brainstorm and try out potential alternative behaviors.

It is important to explore factors in the client's current life that are serving to maintain body image concerns, including triggers for negative thoughts about their appearance, interpretations of their thoughts, emotional reactions, and maladaptive of coping strategies [17].

#### **6.2 Cognitive restructuring**

In cognitive restructuring techniques, the therapist challenges clients' distorted beliefs about their physical appearance by encouraging them to evaluate their beliefs in the light of evidence. Cognitive techniques included identifying their maladaptive thoughts, completing thought records, identifying cognitive errors, applying the downward arrow technique, and self-talk that leads up to rituals and blocks them from engaging in social activities like going out with groups of friends, going to parties, or dating. Therapists will introduce clients to common cognitive errors in BDD, for example, "This scar makes me very disgusting." Clients are then encouraged to monitor their appearance-based thoughts in and outside of the session and identify their cognitive errors, for example, "Why am I nervous about going to the party?" After the client has gained skills in identifying their maladaptive thoughts and cognitive errors, the therapist starts to evaluate thoughts with the clients [17, 66]. Cognitive restructuring entails evaluating maladaptive thoughts with Socratic questioning and identifying cognitive errors with the goal of developing more accurate and helpful beliefs [67].

Clients will be given homework for every session if necessary, and homework will be discussed in early sessions. For example, they were assigned to record the triggers, excessive thinking, and ritual behavior every time when the symptoms appeared. The aim of the thought record homework is to help client to step back from some of their thoughts and reflect on them. In addition, to help them monitor the negative thoughts that link to the repetitive behavior and help them to be aware of when the trigger comes up.

#### **6.3 Exposure and ritual prevention (ERP)**

A form of cognitive behavioral therapy intervention emphasizing exposure and response prevention has been shown to produce marked improvement in 50–80% of treated clients [68]. Exposure and response prevention is a process whereby the rituals are actively prevented and the clients are systematically and gradually exposed to their feared thoughts or situations [69].

Prior to beginning exposure and response prevention, the therapist and clients should review the BDD model to help identify their rituals such as excessive mirror checking, exchanging clothes, comparing themselves with other people, and repeated examining of the imaginary defect. In addition identify avoidance behaviors such as avoiding shopping malls, and discuss the role of rituals and avoidance in maintaining his or her symptoms.

Firstly, therapist and clients jointly develop a hierarchy of anxiety-provoking and avoided situations, such as clients often avoiding daily activities or activities that could reveal one's perceived flaws, including going to a party, going to work or class, or accepting social invitations. The hierarchy should include situations that would broaden a client's overall social experiences. For example, a client might be encouraged to go out with their friends twice per week instead of avoiding friends on days when he or she thought the nose looked really huge [17].

The first exposure should be mildly to moderately challenging, with a high likelihood for success. Exposure can be very challenging for clients; therefore, it is important for the therapist to provide a strong rationale for exposure, validate the client's anxiety while guiding him or her toward change, be challenging and encouraging, be patient and a cheerleader and quickly incorporate ritual prevention [17].

Meanwhile there are several types of strategies to eliminate ritual. First is using stimulus control which requires clients to manipulate their environment to avoid cues that triggers ritual. For example, if the client uses a tool like a mirror for their appearance ritual, the therapist should tell him or her to give it to someone else to keep it temporarily. Secondly, there are methods used to reduce time spent ritualizing. For example, if the client took 1 hour to check the mirror every day, the therapist asks him or her to reduce it by 30 minutes for the next day and then reduce to 25 minutes, reduce to 20 minutes, and reduce to 15 minutes every day and so forth until he or she spent only for a few minutes in checking himself or herself in the mirror. Clients are also encouraged to monitor the frequency and contexts in which rituals arise [17].

This technique will be more effective if clients are encouraged to use ritual prevention strategies during exposure exercises, for example, going to work (exposure) without makeup or delayed makeup (ritual prevention).

Doing homework is an essential ingredient of getting better. Homework is also given between sessions. It involves practicing skills that have been learned in therapy sessions. At various stages of the treatment, clients do exposure or behavioral experiments and ritual prevention as homework [10]. Therapists must always encourage clients to do their homework and give some credits if they did a good job.

#### **6.4 Perceptual retraining**

Individuals with BDD often have a complex relationship with mirrors and reflective surfaces. Clients may hesitate between getting stuck for hours in the mirror, grooming, or skin picking and actively avoiding seeing his or her reflection. Clients focus only on the body parts that are of concern and get very close to the mirror, which magnifies perceived imperfections and maintains maladaptive BDD beliefs and behaviors [17]. Clients also tend to engage in judgmental and emotionally charged self-talk.

Therefore, the goal of perceptual retraining is to develop a healthy relationship with mirrors, so clients do not check themselves excessively or avoid them and to view themselves more realistically [10]. The therapist helps to guide them in describing his or her whole body while standing at a conversational distance from the mirror.

Instead of judgmental language by clients, during perceptual (mirror) retraining, clients learn to describe themselves more objectively. The therapist encourages

**57**

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder*

them to refrain from rituals or repetitive, such as zoning in on disliked areas or touching certain body parts. Perceptual retraining strategies can also be used to broaden client's attention in other situations in which the clients selectively attend to aspects of theirs and others' appearance. For example, while at work, clients are encouraged to practice attending to other things in their environment as opposed to

Relapse prevention techniques may entail scheduling healthy activities to replace

BDD symptoms can be distressing and can interfere to some extent with living. Symptoms cause clinically significant distress or impairment in functioning. Milder BDD is more manageable. People with milder BDD may be productive, and some manage well despite their suffering [10]. People with mild symptoms are easier to

BDD can also be more moderate in severity, and in some cases, it is extremely severe. When BDD is severe, it can destroy virtually every aspect of one's life. Some people will stop working and are stuck in their homes, sometimes for years, and some will drop out of work, high school, or college. Some even get into life-threatening accidents. Some suffer so intolerably that they attempt suicide, and some of

Somehow, individuals with severe symptoms are more hard to engage in and refuse to go for treatment. Many of them are ashamed of their symptoms and are reluctant to reveal them to others [70]. Some individual with BDD are also depressed that it is difficult for them to get motivated to come for treatments. Most of them also do not believe how therapy interventions can help them to alleviate the negative appearance, beliefs, and ritual behavior [17]. Others believe that their situation is hopeless and nothing can be done to help them [17]. Therefore, they decided not to seek any psychological treatment and prefer to choose cosmetic surgery treatment. Some people with BDD also believe that they are normal and very healthy and, hence, do not seek any treatment. They think that their symptoms were not that bad. Moreover, people with BDD also tend to be very sensitive to rejection. Therefore, therapist must be careful to convey a sense of acceptance and concern without reinforcing their inaccurate beliefs about their appearance. In addition motivational strategies are very useful during

BDD is an issue of concern to many people struggling around the world. BDD is a mental illness associated with high morbidity and mortality, and early

and distract from time spent on repetitive or ritual behaviors. The techniques provide clients with various types of treatment alternatives such as skills or activities that can be applied outside the therapy session. Clients and therapist will review which techniques were most helpful for the clients and how they can keep practicing them in the future after the termination of intervention. Clients also do other things, such as anticipating possible future stressors and how they can manage them

*DOI: http://dx.doi.org/10.5772/intechopen.81822*

his own or others' appearance [17].

**6.5 Relapse prevention**

by using CBT skills [10].

them kill themselves [10].

the treatment sessions [17].

**8. Conclusion**

**7. Challenges in treating BDD**

engage in because they are aware of their illness.

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder DOI: http://dx.doi.org/10.5772/intechopen.81822*

them to refrain from rituals or repetitive, such as zoning in on disliked areas or touching certain body parts. Perceptual retraining strategies can also be used to broaden client's attention in other situations in which the clients selectively attend to aspects of theirs and others' appearance. For example, while at work, clients are encouraged to practice attending to other things in their environment as opposed to his own or others' appearance [17].

#### **6.5 Relapse prevention**

*Cognitive Behavioral Therapy - Theories and Applications*

maintaining his or her symptoms.

Prior to beginning exposure and response prevention, the therapist and clients should review the BDD model to help identify their rituals such as excessive mirror checking, exchanging clothes, comparing themselves with other people, and repeated examining of the imaginary defect. In addition identify avoidance behaviors such as avoiding shopping malls, and discuss the role of rituals and avoidance in

Firstly, therapist and clients jointly develop a hierarchy of anxiety-provoking and avoided situations, such as clients often avoiding daily activities or activities that could reveal one's perceived flaws, including going to a party, going to work or class, or accepting social invitations. The hierarchy should include situations that would broaden a client's overall social experiences. For example, a client might be encouraged to go out with their friends twice per week instead of avoiding friends

The first exposure should be mildly to moderately challenging, with a high likelihood for success. Exposure can be very challenging for clients; therefore, it is important for the therapist to provide a strong rationale for exposure, validate the client's anxiety while guiding him or her toward change, be challenging and encouraging, be patient and a cheerleader and quickly incorporate ritual prevention [17]. Meanwhile there are several types of strategies to eliminate ritual. First is using stimulus control which requires clients to manipulate their environment to avoid cues that triggers ritual. For example, if the client uses a tool like a mirror for their appearance ritual, the therapist should tell him or her to give it to someone else to keep it temporarily. Secondly, there are methods used to reduce time spent ritualizing. For example, if the client took 1 hour to check the mirror every day, the therapist asks him or her to reduce it by 30 minutes for the next day and then reduce to 25 minutes, reduce to 20 minutes, and reduce to 15 minutes every day and so forth until he or she spent only for a few minutes in checking himself or herself in the mirror. Clients are also encouraged to monitor the frequency and contexts in which rituals arise [17]. This technique will be more effective if clients are encouraged to use ritual prevention strategies during exposure exercises, for example, going to work (exposure)

Doing homework is an essential ingredient of getting better. Homework is also given between sessions. It involves practicing skills that have been learned in therapy sessions. At various stages of the treatment, clients do exposure or behavioral experiments and ritual prevention as homework [10]. Therapists must always encourage clients to do their homework and give some credits if they did a good job.

Individuals with BDD often have a complex relationship with mirrors and reflective surfaces. Clients may hesitate between getting stuck for hours in the mirror, grooming, or skin picking and actively avoiding seeing his or her reflection. Clients focus only on the body parts that are of concern and get very close to the mirror, which magnifies perceived imperfections and maintains maladaptive BDD beliefs and behaviors [17]. Clients also tend to engage in judgmental and emotionally

Therefore, the goal of perceptual retraining is to develop a healthy relationship with mirrors, so clients do not check themselves excessively or avoid them and to view themselves more realistically [10]. The therapist helps to guide them in describing his or her whole body while standing at a conversational distance from

Instead of judgmental language by clients, during perceptual (mirror) retraining, clients learn to describe themselves more objectively. The therapist encourages

on days when he or she thought the nose looked really huge [17].

without makeup or delayed makeup (ritual prevention).

**6.4 Perceptual retraining**

charged self-talk.

the mirror.

**56**

Relapse prevention techniques may entail scheduling healthy activities to replace and distract from time spent on repetitive or ritual behaviors. The techniques provide clients with various types of treatment alternatives such as skills or activities that can be applied outside the therapy session. Clients and therapist will review which techniques were most helpful for the clients and how they can keep practicing them in the future after the termination of intervention. Clients also do other things, such as anticipating possible future stressors and how they can manage them by using CBT skills [10].

#### **7. Challenges in treating BDD**

BDD symptoms can be distressing and can interfere to some extent with living. Symptoms cause clinically significant distress or impairment in functioning. Milder BDD is more manageable. People with milder BDD may be productive, and some manage well despite their suffering [10]. People with mild symptoms are easier to engage in because they are aware of their illness.

BDD can also be more moderate in severity, and in some cases, it is extremely severe. When BDD is severe, it can destroy virtually every aspect of one's life. Some people will stop working and are stuck in their homes, sometimes for years, and some will drop out of work, high school, or college. Some even get into life-threatening accidents. Some suffer so intolerably that they attempt suicide, and some of them kill themselves [10].

Somehow, individuals with severe symptoms are more hard to engage in and refuse to go for treatment. Many of them are ashamed of their symptoms and are reluctant to reveal them to others [70]. Some individual with BDD are also depressed that it is difficult for them to get motivated to come for treatments. Most of them also do not believe how therapy interventions can help them to alleviate the negative appearance, beliefs, and ritual behavior [17]. Others believe that their situation is hopeless and nothing can be done to help them [17]. Therefore, they decided not to seek any psychological treatment and prefer to choose cosmetic surgery treatment. Some people with BDD also believe that they are normal and very healthy and, hence, do not seek any treatment. They think that their symptoms were not that bad. Moreover, people with BDD also tend to be very sensitive to rejection. Therefore, therapist must be careful to convey a sense of acceptance and concern without reinforcing their inaccurate beliefs about their appearance. In addition motivational strategies are very useful during the treatment sessions [17].

#### **8. Conclusion**

BDD is an issue of concern to many people struggling around the world. BDD is a mental illness associated with high morbidity and mortality, and early

#### *Cognitive Behavioral Therapy - Theories and Applications*

intervention is crucial for recovery to improve their life function. Treating BDD is very challenging for therapists, and CBT is a promised intervention for treating BDD [34, 60]. Therefore, research on psychotherapy for BDD is greatly needed. More research needs to be done to determine how well CBT works and which CBT techniques are most effective and whether other new techniques should be added for the effectiveness of the intervention. Research is also needed to find out for whom CBT works best and how to adapt it, specifically for adolescents and adults. On top of that, researchers, therapists, clinicians, and counselors are yielded to conduct more cross-cultural research in attempting to understand BDD culturally. Lastly, a study on a combination of CBT with pharmacological treatment is recommended.

#### **Author details**

Norzihan Ayub\*, Patricia Joseph Kimong and Guan Teik Ee Faculty of Psychology and Education, Universiti Malaysia Sabah, Sabah, Malaysia

\*Address all correspondence to: norzihan@ums.edu.my

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**59**

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder*

characteristics, phenomenology, comorbidity, and family history in 200 individuals with body

psy.46.4.317

janxdis.2007.05.004

University Press; 2009

disorder. The Journal of Nervous and Mental Disease. 1997;**185**(9):570-577. DOI:

10.1002/da.20709

S0005-7967(00)00102-9

Current Psychiatry Reports.

2002;**4**(2):108-113

dysmorphic disorder. Psychosomatics. 2005;**46**(4):317-325. DOI: 10.1176/appi.

[9] Buhlmann U, Etcoff NL, Wilhelm S. Facial attractiveness ratings and perfectionism in body dysmorphic disorder and obsessive-compulsive disorder. Journal of Anxiety Disorders. 2008;**22**(3):540-547. DOI: 10.1016/j.

[10] Phillips KA. Understanding Body Dysmorphic Disorder: An Essential Guide. New York, NY, US: Oxford

[11] Phillips KA, Diaz SF. Gender differences in body dysmorphic

10.1097/00005053-199709000-00006

[12] Phillips KA, Wilhelm S, Koran LM, Didie ER, Fallon BA, Feusner J, et al. Body dysmorphic disorder: Some key issues for DSM-V. Depression and Anxiety. 2010;**27**(6):573-591. DOI:

[13] Veale D, Riley S. 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. 2001;**39**(12):1381-1393. DOI: 10.1016/

[14] Hadley SJ, Greenberg J, Hollander E. Diagnosing and treatment of body dysmorphic disorder in adolescents.

[15] Phillips KA, Didie ER, Menard W, Pagano ME, Fay C, Weisberg RB. Clinical features of body

*DOI: http://dx.doi.org/10.5772/intechopen.81822*

university students. Eurasian Journal of Educational Research. 2016;**64**:31-44.

[2] Sarcu D, Adamson P. Psychology of the facelift patient. Facial Plastic Surgery. 2017;**33**(3):252-259. DOI:

[3] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder. 5 th ed. Washington, DC: American Psychiatric Publication;

[4] Phillips KA, Menard W, Pagano M, Fay C, Stout RL. Delusional versus nondelusional body dysmorphic

[5] Phillips KA, Rogers J. Cognitivebehavioral therapy for youth with body dysmorphic disorder: Current status and future directions. Child and Adolescent Psychiatric Clinics of North America. 2011;**20**(2):287-304. DOI: 10.1016/j.

[6] Sarwer DB, Crerand CE, Magee L. Body dysmorphic disorder in patients who seek appearance-enhancing medical treatments. Oral and

Maxillofacial Surgery Clinics of North America. 2010;**22**(4):445-453. DOI:

10.1016/j.coms.2010.07.002

[7] Greenberg JL, Markowitz S, Petronko MR, Taylor CE, Wilhelm S, Wilson GT. Cognitive-behavioral therapy for adolescent body dysmorphic disorder. Cognitive and Behavioral Practice. 2010;**17**:248-258. DOI: 10.1016/j.cbpra.2010.02.002

[8] Phillips KA, Menard W, Fay C, Weisberg R. Demographic

disorder: Clinical features and course of illness. Journal of Psychiatric Research. 2006;**40**(2):95-104. DOI: 10.1016/j.

[1] Pop C. Self-esteem and body image perception in a sample of

DOI: 10.14689/ejer. 2016.64.2

10.1055/s-0037-1598071

jpsychires.2005.08.005

chc.2011.01.004

2013

**References**

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder DOI: http://dx.doi.org/10.5772/intechopen.81822*

#### **References**

*Cognitive Behavioral Therapy - Theories and Applications*

intervention is crucial for recovery to improve their life function. Treating BDD is very challenging for therapists, and CBT is a promised intervention for treating BDD [34, 60]. Therefore, research on psychotherapy for BDD is greatly needed. More research needs to be done to determine how well CBT works and which CBT techniques are most effective and whether other new techniques should be added for the effectiveness of the intervention. Research is also needed to find out for whom CBT works best and how to adapt it, specifically for adolescents and adults. On top of that, researchers, therapists, clinicians, and counselors are yielded to conduct more cross-cultural research in attempting to understand BDD culturally. Lastly, a study on a combination of CBT with pharmacological treatment is

**58**

**Author details**

recommended.

provided the original work is properly cited.

Norzihan Ayub\*, Patricia Joseph Kimong and Guan Teik Ee

\*Address all correspondence to: norzihan@ums.edu.my

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Faculty of Psychology and Education, Universiti Malaysia Sabah, Sabah, Malaysia

[1] Pop C. Self-esteem and body image perception in a sample of university students. Eurasian Journal of Educational Research. 2016;**64**:31-44. DOI: 10.14689/ejer. 2016.64.2

[2] Sarcu D, Adamson P. Psychology of the facelift patient. Facial Plastic Surgery. 2017;**33**(3):252-259. DOI: 10.1055/s-0037-1598071

[3] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder. 5 th ed. Washington, DC: American Psychiatric Publication; 2013

[4] Phillips KA, Menard W, Pagano M, Fay C, Stout RL. Delusional versus nondelusional body dysmorphic disorder: Clinical features and course of illness. Journal of Psychiatric Research. 2006;**40**(2):95-104. DOI: 10.1016/j. jpsychires.2005.08.005

[5] Phillips KA, Rogers J. Cognitivebehavioral therapy for youth with body dysmorphic disorder: Current status and future directions. Child and Adolescent Psychiatric Clinics of North America. 2011;**20**(2):287-304. DOI: 10.1016/j. chc.2011.01.004

[6] Sarwer DB, Crerand CE, Magee L. Body dysmorphic disorder in patients who seek appearance-enhancing medical treatments. Oral and Maxillofacial Surgery Clinics of North America. 2010;**22**(4):445-453. DOI: 10.1016/j.coms.2010.07.002

[7] Greenberg JL, Markowitz S, Petronko MR, Taylor CE, Wilhelm S, Wilson GT. Cognitive-behavioral therapy for adolescent body dysmorphic disorder. Cognitive and Behavioral Practice. 2010;**17**:248-258. DOI: 10.1016/j.cbpra.2010.02.002

[8] Phillips KA, Menard W, Fay C, Weisberg R. Demographic

characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics. 2005;**46**(4):317-325. DOI: 10.1176/appi. psy.46.4.317

[9] Buhlmann U, Etcoff NL, Wilhelm S. Facial attractiveness ratings and perfectionism in body dysmorphic disorder and obsessive-compulsive disorder. Journal of Anxiety Disorders. 2008;**22**(3):540-547. DOI: 10.1016/j. janxdis.2007.05.004

[10] Phillips KA. Understanding Body Dysmorphic Disorder: An Essential Guide. New York, NY, US: Oxford University Press; 2009

[11] Phillips KA, Diaz SF. Gender differences in body dysmorphic disorder. The Journal of Nervous and Mental Disease. 1997;**185**(9):570-577. DOI: 10.1097/00005053-199709000-00006

[12] Phillips KA, Wilhelm S, Koran LM, Didie ER, Fallon BA, Feusner J, et al. Body dysmorphic disorder: Some key issues for DSM-V. Depression and Anxiety. 2010;**27**(6):573-591. DOI: 10.1002/da.20709

[13] Veale D, Riley S. 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. 2001;**39**(12):1381-1393. DOI: 10.1016/ S0005-7967(00)00102-9

[14] Hadley SJ, Greenberg J, Hollander E. Diagnosing and treatment of body dysmorphic disorder in adolescents. Current Psychiatry Reports. 2002;**4**(2):108-113

[15] Phillips KA, Didie ER, Menard W, Pagano ME, Fay C, Weisberg RB. Clinical features of body

dysmorphic disorder in adolescents and adults. Psychiatry Research. 2006;**141**(3):305-314. DOI: 10.1016/j. psychres.2005.09.014

[16] Buhlmann U, Marques LM, Wilhelm S. Traumatic experiences in individuals with body dysmorphic disorder. The Journal of Nervous and Mental Disease. 2012;**200**(1):95-98. DOI: 10.1097/ NMD.0b013e31823f6775

[17] Wilhelm S, Philips KA, Steketee G. A Treatment Manual : Cognitive Behavioral Therapy for Body Dysmorphic Disorder. New York: The Guilford Press; 2013

[18] Albertini RS, Phillips KA. Thirtythree cases of body dysmorphic disorder in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry. 1999;**38**(4):453-459. DOI: 10.1097/00004583-199904000-00019

[19] Mancuso SG, Knoesen NP, Castle DJ. Delusional vs nondelusional body dysmorphic disorder. Comprehensive Psychiatry. 2010;**51**(2):177-182. DOI: 10.1016/j.comppsych.2009.05.001

[20] Phillips KA, Menard W, Faya C, Pagano ME. Psychosocial functioning and quality of life in body dysmorphic disorder. Comprehensive Psychiatry. 2005;**46**(4):254-260. DOI: 10.1016/j. comppsych.2004.10.004

[21] Gunstad J, Phillips KA. Axis I comorbidity in body dysmorphic disorder. Comprehensive Psychiatry. 2003;**44**(4):270-276. DOI: 10.1016/ S0010440X(03)00088-9

[22] Phillips KA, Stein DJ, Rauch SL, Hollander E, Fallon BA, Barsky A, et al. Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V? Depression and Anxiety. 2010;**27**(6):528-555. DOI: 10.1002/da.20705

[23] Grant JE, Menard W, Pagano ME, Fay C, Phillips KA. Substance use disorders in individuals with body dysmorphic disorder. The Journal of Clinical Psychiatry. 2005;**66**(3):309-316

[24] Bjornsson AS, Didie ER, Phillips KA. Body dysmorphic disorder. Dialogues in Clinical Neuroscience. 2010;**12**(2):221-232

[25] Satel SL, McDougle CJ. Obsessions and compulsions with cocaine abuse [letter]. The American Journal of Psychiatry. 1991;**48**:947

[26] Phillips KA, Menard W. Suicidality in body dysmorphic disorder: A prospective study. The American Journal of Psychiatry. 2006;**163**(7):1280- 1282. DOI: 10.1176/appi.ajp.163.7.1280

[27] Phillips KA. Body dysmorphic disorder: Recognizing and treating imagined ugliness. World Psychiatry. 2004;**3**(1):12-17

[28] Angelakis I, Gooding PA, Panagioti M. Suicidality in body dysmorphic disorder (BDD): A systematic review with meta-analysis. Clinical Psychology Review. 2016;**49**:55-66. DOI: 10.1016/j. cpr.2016.08.002

[29] Witte TK, Didie ER, Menard W, Phillips KA. The relationship between body dysmorphic disorder behaviors and the acquired capability for suicide. Suicide & Life-Threatening Behavior. 2012;**42**(3):318-331. DOI: 10.1111/j.1943-278X.2012.00093

[30] Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R, et al. Body dysmorphic disorder: A survey of fifty cases. The British Journal of Psychiatry. 1996;**169**(2):196-220. DOI: 10.1192/bjp.169.2.196

[31] Wilhelm S, Neziroglu F. Cognitive theory of body dysmorphic disorder. In: Frost RO, Steketee G, editors. Cognitive Approaches to Obsessions and

**61**

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder*

[39] Monzani B, Rijsdijk F, Lervolino AC, Anson M, Cherkas L, Mataix-Cols D. Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample. American Journal of Medical Genetics. Part B, Neuropsychiatric Genetics. 2012;**159B**(4):376-382. DOI: 10.1002/

[40] Monzani B, Rijsdijk F, Anson M, Lervolino AC, Cherkas L, Spector T, et al. A twin study of body dysmorphic concerns. Psychological Medicine. 2012;**42**(9):1949-1955. DOI: 10.1017/

ajmg.b.32040

S0033291711002741

ajmg.b.32233

1978;**25**:47-54

[41] Lopez-Sola C, Fontenelle LF, Alonso P, Cuadras D, Foley DL, Pantelis C, et al. Prevalence and heritability of obsessive compulsive spectrum and anxiety disorder symptoms: A survey of the Australian twin registry. American Journal of Medical Genetics. Part B, Neuropsychiatric Genetics. 2014;**165B**:314-325. DOI: 10.1002/

[42] Yamada M, Kobashi K, Shigemoto T, et al. On dismorphophobia. The Bulletin of the Yamaguchi Medical School.

[43] Turkson SN, Asamoah V. Body dysmorphic disorder in a Ghanaian male: Case report. East African Medical

[44] Ung EK, Fones CS, Ang AW. Muscle dysmorphia in a young Chinese male. Annals Academy of Medicine Singapore.

Toulopoulou T, Tsuchiya KJ, Matsumoto K, et al. Jiko-shisen-kyofu (fear of one's own glance), but not taijinkyofusho (fear of interpersonal relations), is an east Asian culturerelated specific syndrome. The

Australian and New Zealand Journal of

Journal. 1999;**76**(2):111-114

[45] Iwata Y, Suzuki K, Takei N,

2000;**29**(1):135-137

*DOI: http://dx.doi.org/10.5772/intechopen.81822*

Compulsions: Theory, Assessment, and Treatment. New York, NY: Pergamon; 2002. pp. 203-214. DOI: 10.1016/B978-

[32] Beck AT, Rush A, Shaw B, Emery G. Cognitive Therapy of Depression. New York: Guilford Press; 1979

[33] Deckersbach T, Otto MW, Savage CR, Baer L, Jenike MA. The relationship between semantic organization and memory in obsessive - compulsive disorder. Psychotherapy and

Psychosomatics. 2000;**69**(2):101-107.

[34] Veale D. Cognitive-behavioural therapy for body dysmorphic disorder. Advances in Psychiatric Treatment.

[35] Feusner JD, Moody T, Hembacher E, Townsend J, McKinley M, Moller H, et al. Abnormalities of visual processing and frontostriatal systems

in body dysmorphic disorder. Archives of General Psychiatry. 2010;**67**(2):197-205. DOI: 10.1001/ archgenpsychiatry.2009.190

[36] Atmaca M, Bingol I, Aydin A, Yildirim H, Okur I, Yildirim MA, et al. Brain morphology of patients with body dysmorphic disorder. Journal of Affective Disorders. 2010;**123**(1-3):258- 263. DOI: 10.1016/j.jad.2009.08.012

[37] Feusner JD, Townsend J, Bystritsky A, Bookheimer S. Visual information processing of faces in body dysmorphic

Psychiatry. 2007;**64**(12):1417-1425. DOI:

[38] Bienvenu O, Samuels J, Riddle M, Hoehn-Saric R, Liang K, Cullen B, et al. The relationship of obsessivecompulsive disorder to possible spectrum disorders: Results from a family study. Biological Psychiatry. 2000;**48**(4):287-293. DOI: 10.1016/

disorder. Archives of General

10.1001/archpsyc.64.12.1417

S0006-3223(00)00831-3

0-08-043410-0.X5000-4

DOI: 10.1159/000012373

2001;**7**:125-132

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder DOI: http://dx.doi.org/10.5772/intechopen.81822*

Compulsions: Theory, Assessment, and Treatment. New York, NY: Pergamon; 2002. pp. 203-214. DOI: 10.1016/B978- 0-08-043410-0.X5000-4

[32] Beck AT, Rush A, Shaw B, Emery G. Cognitive Therapy of Depression. New York: Guilford Press; 1979

[33] Deckersbach T, Otto MW, Savage CR, Baer L, Jenike MA. The relationship between semantic organization and memory in obsessive - compulsive disorder. Psychotherapy and Psychosomatics. 2000;**69**(2):101-107. DOI: 10.1159/000012373

[34] Veale D. Cognitive-behavioural therapy for body dysmorphic disorder. Advances in Psychiatric Treatment. 2001;**7**:125-132

[35] Feusner JD, Moody T, Hembacher E, Townsend J, McKinley M, Moller H, et al. Abnormalities of visual processing and frontostriatal systems in body dysmorphic disorder. Archives of General Psychiatry. 2010;**67**(2):197-205. DOI: 10.1001/ archgenpsychiatry.2009.190

[36] Atmaca M, Bingol I, Aydin A, Yildirim H, Okur I, Yildirim MA, et al. Brain morphology of patients with body dysmorphic disorder. Journal of Affective Disorders. 2010;**123**(1-3):258- 263. DOI: 10.1016/j.jad.2009.08.012

[37] Feusner JD, Townsend J, Bystritsky A, Bookheimer S. Visual information processing of faces in body dysmorphic disorder. Archives of General Psychiatry. 2007;**64**(12):1417-1425. DOI: 10.1001/archpsyc.64.12.1417

[38] Bienvenu O, Samuels J, Riddle M, Hoehn-Saric R, Liang K, Cullen B, et al. The relationship of obsessivecompulsive disorder to possible spectrum disorders: Results from a family study. Biological Psychiatry. 2000;**48**(4):287-293. DOI: 10.1016/ S0006-3223(00)00831-3

[39] Monzani B, Rijsdijk F, Lervolino AC, Anson M, Cherkas L, Mataix-Cols D. Evidence for a genetic overlap between body dysmorphic concerns and obsessive-compulsive symptoms in an adult female community twin sample. American Journal of Medical Genetics. Part B, Neuropsychiatric Genetics. 2012;**159B**(4):376-382. DOI: 10.1002/ ajmg.b.32040

[40] Monzani B, Rijsdijk F, Anson M, Lervolino AC, Cherkas L, Spector T, et al. A twin study of body dysmorphic concerns. Psychological Medicine. 2012;**42**(9):1949-1955. DOI: 10.1017/ S0033291711002741

[41] Lopez-Sola C, Fontenelle LF, Alonso P, Cuadras D, Foley DL, Pantelis C, et al. Prevalence and heritability of obsessive compulsive spectrum and anxiety disorder symptoms: A survey of the Australian twin registry. American Journal of Medical Genetics. Part B, Neuropsychiatric Genetics. 2014;**165B**:314-325. DOI: 10.1002/ ajmg.b.32233

[42] Yamada M, Kobashi K, Shigemoto T, et al. On dismorphophobia. The Bulletin of the Yamaguchi Medical School. 1978;**25**:47-54

[43] Turkson SN, Asamoah V. Body dysmorphic disorder in a Ghanaian male: Case report. East African Medical Journal. 1999;**76**(2):111-114

[44] Ung EK, Fones CS, Ang AW. Muscle dysmorphia in a young Chinese male. Annals Academy of Medicine Singapore. 2000;**29**(1):135-137

[45] Iwata Y, Suzuki K, Takei N, Toulopoulou T, Tsuchiya KJ, Matsumoto K, et al. Jiko-shisen-kyofu (fear of one's own glance), but not taijinkyofusho (fear of interpersonal relations), is an east Asian culturerelated specific syndrome. The Australian and New Zealand Journal of

**60**

*Cognitive Behavioral Therapy - Theories and Applications*

[23] Grant JE, Menard W, Pagano ME, Fay C, Phillips KA. Substance use disorders in individuals with body dysmorphic disorder. The Journal of Clinical Psychiatry. 2005;**66**(3):309-316

[24] Bjornsson AS, Didie ER, Phillips KA. Body dysmorphic disorder. Dialogues in Clinical Neuroscience.

[25] Satel SL, McDougle CJ. Obsessions and compulsions with cocaine abuse [letter]. The American Journal of

[26] Phillips KA, Menard W. Suicidality in body dysmorphic disorder: A prospective study. The American Journal of Psychiatry. 2006;**163**(7):1280- 1282. DOI: 10.1176/appi.ajp.163.7.1280

[27] Phillips KA. Body dysmorphic disorder: Recognizing and treating imagined ugliness. World Psychiatry.

[28] Angelakis I, Gooding PA, Panagioti M. Suicidality in body dysmorphic disorder (BDD): A systematic review with meta-analysis. Clinical Psychology Review. 2016;**49**:55-66. DOI: 10.1016/j.

[29] Witte TK, Didie ER, Menard W, Phillips KA. The relationship between body dysmorphic disorder behaviors and the acquired capability for suicide. Suicide & Life-Threatening Behavior. 2012;**42**(3):318-331. DOI: 10.1111/j.1943-278X.2012.00093

[30] Veale D, Boocock A, Gournay K, Dryden W, Shah F, Willson R, et al. Body dysmorphic disorder: A survey of fifty cases. The British Journal of Psychiatry. 1996;**169**(2):196-220. DOI:

[31] Wilhelm S, Neziroglu F. Cognitive theory of body dysmorphic disorder. In: Frost RO, Steketee G, editors.

Cognitive Approaches to Obsessions and

10.1192/bjp.169.2.196

2010;**12**(2):221-232

Psychiatry. 1991;**48**:947

2004;**3**(1):12-17

cpr.2016.08.002

dysmorphic disorder in adolescents and adults. Psychiatry Research. 2006;**141**(3):305-314. DOI: 10.1016/j.

[16] Buhlmann U, Marques LM, Wilhelm S. Traumatic experiences in individuals with body dysmorphic disorder. The Journal of Nervous and Mental Disease. 2012;**200**(1):95-98. DOI: 10.1097/

[17] Wilhelm S, Philips KA, Steketee G. A Treatment Manual : Cognitive Behavioral Therapy for Body

Dysmorphic Disorder. New York: The

[18] Albertini RS, Phillips KA. Thirtythree cases of body dysmorphic disorder in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry.

10.1097/00004583-199904000-00019

[19] Mancuso SG, Knoesen NP, Castle DJ. Delusional vs nondelusional body dysmorphic disorder. Comprehensive Psychiatry. 2010;**51**(2):177-182. DOI: 10.1016/j.comppsych.2009.05.001

[20] Phillips KA, Menard W, Faya C, Pagano ME. Psychosocial functioning and quality of life in body dysmorphic disorder. Comprehensive Psychiatry. 2005;**46**(4):254-260. DOI: 10.1016/j.

[21] Gunstad J, Phillips KA. Axis I comorbidity in body dysmorphic disorder. Comprehensive Psychiatry. 2003;**44**(4):270-276. DOI: 10.1016/

[22] Phillips KA, Stein DJ, Rauch SL, Hollander E, Fallon BA, Barsky A, et al. Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V? Depression and Anxiety. 2010;**27**(6):528-555. DOI:

comppsych.2004.10.004

S0010440X(03)00088-9

10.1002/da.20705

psychres.2005.09.014

NMD.0b013e31823f6775

Guilford Press; 2013

1999;**38**(4):453-459. DOI:

Psychiatry. 2011;**45**(2):148-152. DOI: 10.3109/00048674.2010.534068

[46] Oh NR, An SY, Jeong MA. Relationship of BMI to body dysmorphic disorder among college students in Gangwon Province. Journal of the Korea Academia-Industrial Cooperation Society. 2013;**14**(7):3293- 3300. DOI: 10.5762/KAIS.2013.14.7.3293

[47] Brito MJ, Nahas FX, Cordás TA, Gama MG, Sucupira ER, Ramos TD, et al. Prevalence of body dysmorphic disorder symptoms and body weight concerns in patients seeking abdominoplasty. Aesthetic Surgery Journal. 2016;**36**(3):324-332. DOI: 10.1093/asj/sjv213

[48] Jeremy GCG, Stephen L. Prevalence of body dysmorphic disorder and impact on subjective outcome amongst Singaporean rhinoplasty patients. Anaplastology. 2015;**4**:140. DOI: 10.4172/2161-1173.1000140

[49] Bohne A, Keuthen NJ, Wilhelm S, Deckersbach T, Jenike MA. Prevalence of symptoms of body dysmorphic disorder and its correlates: A crosscultural comparison. Psychosomatics. 2002;**43**(6):486-490. DOI: 10.1176/appi. psy.43.6.486

[50] Bernstein IH, Lin TD, McClellan P. Cross-vs. within-racial judgments of attractiveness. Perception & Psychophysics. 198*2*;**32**(6):495-503. DOI: 10.3758/BF03204202

[51] Weingarden H, Curley EE, Renshaw KD, Wilhelm S. Patient-identified events implicated in the development of body dysmorphic disorder. Body Image. 2017;**21**:19-25. DOI: 10.1016/j. bodyim.2017.02.003

[52] Webb HJ, Zimmer-Gembeck MJ, Mastro S, Farrell LJ, Lavell CH. Young adolescents' body dysmorphic symptoms: Associations with same-and cross-sex peer teasing via

appearance-based rejection sensitivity. Journal of Abnormal Child Psychology. 2015;**43**(6):1161-1173. DOI: 10.1007/ s10802-014-9971-9

[53] Webb HJ, Zimmer-Gembeck MJ, Mastro S. Stress exposure and generation: A conjoint longitudinal model of body dysmorphic symptoms, peer acceptance, popularity, and victimization. Body Image. 2016;**18**:14- 18. DOI: 10.1016/j.bodyim.2016.04.010

[54] Didie ER, Tortolani CC, Pope CG, Menard W, Fay C, Phillips KA. Childhood abuse and neglect in body dysmorphic disorder. Child Abuse & Neglect. 2006;**30**(10):1105-1115. DOI: 10.1016/j.chiabu.2006.03.007

[55] Silverman AB, Reinherz HZ, Giaconia RM. The long-term sequelae of child and adolescent abuse: A longitudinal community study. Child Abuse & Neglect. 1996;**20**(8):709-723. DOI: 10.1016/0145-2134(96)00059-2

[56] Walker JL, Carey PD, Mohr N, Stein DJ, Seedat S. Gender differences in the prevalence of childhood sexual abuse and in the development of pediatric PTSD. Archives of Women's Mental Health. 2002;**7**:111-121. DOI: 10.1007/ s00737-003-0039-z

[57] Veale D, Neziroglu F. Body Dysmorphic Disorder. A Treatment Manual. Wiley-Blackwell. UK: John Wiley & Sons, Ltd; 2010

[58] Rhodes G. The evolutionary psychology of facial beauty. Annual Review of Psychology. 2006;**57**:199- 226. DOI: 10.1146/annurev. psych.57.102904.190208

[59] Feusner JD, Bystritsky A, Hellemann G, Bookheimer S. Impaired identity recognition of faces with emotional expressions in body dysmorphic disorder. Psychiatry Research. 2010;**179**(3):318-323. DOI: 10.1016/j.psychres.2009.01.016

**63**

*A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder*

Guide. New York: Springer; 2015. DOI:

[68] Sarwer DB, Gibbons LM, Crerand CE. Treating body dysmorphic disorder with cognitive-behaviour therapy. Psychiatric Annals. 2004;**34**:934-931

[69] Abramowitz JS, Taylor S, McKay D. Exposure-based treatment for obsessive compulsive disorder. In: Steketee G, editor. The Oxford Handbook of Obsessive Compulsive and Spectrum Disorders. New York, NY: Oxford University Press; 2012. pp. 322-364. DOI: 10.1093/oxfor dhb/9780195376210.001.0001

[70] Grant JE, Kim SW, Crow SJ.

Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. The Journal of Clinical Psychiatry. 2001;**62**:517-522

10.1007/978-3-319-17867-7

*DOI: http://dx.doi.org/10.5772/intechopen.81822*

[60] Wilhelm S, Phillips KA, Didie E, Buhlmann U, Greenberg JL, Fama JM, et al. Modular cognitive-behavioral therapy for body dysmorphic disorder: Randomized controlled trial. Behavior Therapy. 2014;**45**(3):314-332. DOI:

10.1016/j.beth.2013.12.007

10.2147/NDT.S41074

[61] Prazeres AM, Nascimento AL, Fontenelle LF. Cognitive-behavioral therapy for body dysmorphic disorder: A review of its efficacy. Neuropsychiatric Disease and Treatment. 2013;**9**:307-316. DOI:

[62] Neziroglu F, Khemlani-Patel S. A review of cognitive and behavioral treatment for body dysmorphic disorder. CNS Spectrums. 2002;**7**(6):464-471. DOI: 10.1017/S1092852900017971

[63] McKay D, Todaro J, Neziroglu F, Campisi T, Moritz EK, Yaryura-Tobias JA. Body dysmorphic disorder: A preliminary evaluation of treatment and maintenance using exposure with response prevention. Behaviour Research and Therapy. 1997;**35**(1):67-70. DOI: 10.1016/S0005-7967(96)00082-4

[64] Geremia GM, Neziroglu F. Cognitive therapy in the treatment of body dysmorphic disorder. Clinical Psychology & Psychotherapy.

10.1177/0145445599234006

1996;**34**(9):717-729

[66] Veale D, Gournay K, Dryden W, Boocock A, Shah F, Willson R, et al. Body dysmorphic disorder. A cognitive behavioural model and pilot randomized controlled trial. Behaviour Research and Therapy.

[67] Vashi NA. Beauty and Body Dysmorphic Disorder: A Clinician's

2001;**8**(4):243-251. DOI: 10.1002/cpp.284

[65] McKay D. Two-year follow-up of behavioral treatment and maintenance for body dysmorphic disorder. Behavior Modification. 1999;**23**(4):620-629. DOI: *A Distorted Body Image: Cognitive Behavioral Therapy for Body Dysmorphic Disorder DOI: http://dx.doi.org/10.5772/intechopen.81822*

[60] Wilhelm S, Phillips KA, Didie E, Buhlmann U, Greenberg JL, Fama JM, et al. Modular cognitive-behavioral therapy for body dysmorphic disorder: Randomized controlled trial. Behavior Therapy. 2014;**45**(3):314-332. DOI: 10.1016/j.beth.2013.12.007

*Cognitive Behavioral Therapy - Theories and Applications*

appearance-based rejection sensitivity. Journal of Abnormal Child Psychology. 2015;**43**(6):1161-1173. DOI: 10.1007/

[53] Webb HJ, Zimmer-Gembeck MJ, Mastro S. Stress exposure and generation: A conjoint longitudinal model of body dysmorphic symptoms, peer acceptance, popularity, and victimization. Body Image. 2016;**18**:14- 18. DOI: 10.1016/j.bodyim.2016.04.010

[54] Didie ER, Tortolani CC, Pope CG, Menard W, Fay C, Phillips KA. Childhood abuse and neglect in body dysmorphic disorder. Child Abuse & Neglect. 2006;**30**(10):1105-1115. DOI:

10.1016/j.chiabu.2006.03.007

s00737-003-0039-z

[57] Veale D, Neziroglu F. Body Dysmorphic Disorder. A Treatment Manual. Wiley-Blackwell. UK: John

[58] Rhodes G. The evolutionary psychology of facial beauty. Annual Review of Psychology. 2006;**57**:199-

Wiley & Sons, Ltd; 2010

226. DOI: 10.1146/annurev. psych.57.102904.190208

[59] Feusner JD, Bystritsky A,

Hellemann G, Bookheimer S. Impaired identity recognition of faces with emotional expressions in body dysmorphic disorder. Psychiatry Research. 2010;**179**(3):318-323. DOI: 10.1016/j.psychres.2009.01.016

[55] Silverman AB, Reinherz HZ, Giaconia RM. The long-term sequelae of child and adolescent abuse: A longitudinal community study. Child Abuse & Neglect. 1996;**20**(8):709-723. DOI: 10.1016/0145-2134(96)00059-2

[56] Walker JL, Carey PD, Mohr N, Stein DJ, Seedat S. Gender differences in the prevalence of childhood sexual abuse and in the development of pediatric PTSD. Archives of Women's Mental Health. 2002;**7**:111-121. DOI: 10.1007/

s10802-014-9971-9

Psychiatry. 2011;**45**(2):148-152. DOI: 10.3109/00048674.2010.534068

MA. Relationship of BMI to body dysmorphic disorder among college students in Gangwon Province. Journal of the Korea Academia-Industrial Cooperation Society. 2013;**14**(7):3293- 3300. DOI: 10.5762/KAIS.2013.14.7.3293

[47] Brito MJ, Nahas FX, Cordás TA, Gama MG, Sucupira ER, Ramos TD, et al. Prevalence of body dysmorphic

[48] Jeremy GCG, Stephen L. Prevalence of body dysmorphic disorder and impact on subjective outcome amongst Singaporean rhinoplasty patients. Anaplastology. 2015;**4**:140. DOI: 10.4172/2161-1173.1000140

[49] Bohne A, Keuthen NJ, Wilhelm S, Deckersbach T, Jenike MA. Prevalence of symptoms of body dysmorphic disorder and its correlates: A crosscultural comparison. Psychosomatics. 2002;**43**(6):486-490. DOI: 10.1176/appi.

[50] Bernstein IH, Lin TD, McClellan P. Cross-vs. within-racial judgments of attractiveness. Perception & Psychophysics. 198*2*;**32**(6):495-503.

[51] Weingarden H, Curley EE, Renshaw KD, Wilhelm S. Patient-identified events implicated in the development of body dysmorphic disorder. Body Image. 2017;**21**:19-25. DOI: 10.1016/j.

[52] Webb HJ, Zimmer-Gembeck MJ, Mastro S, Farrell LJ, Lavell CH. Young

adolescents' body dysmorphic symptoms: Associations with same-and cross-sex peer teasing via

DOI: 10.3758/BF03204202

bodyim.2017.02.003

disorder symptoms and body weight concerns in patients seeking abdominoplasty. Aesthetic Surgery Journal. 2016;**36**(3):324-332. DOI:

10.1093/asj/sjv213

psy.43.6.486

[46] Oh NR, An SY, Jeong

**62**

[61] Prazeres AM, Nascimento AL, Fontenelle LF. Cognitive-behavioral therapy for body dysmorphic disorder: A review of its efficacy. Neuropsychiatric Disease and Treatment. 2013;**9**:307-316. DOI: 10.2147/NDT.S41074

[62] Neziroglu F, Khemlani-Patel S. A review of cognitive and behavioral treatment for body dysmorphic disorder. CNS Spectrums. 2002;**7**(6):464-471. DOI: 10.1017/S1092852900017971

[63] McKay D, Todaro J, Neziroglu F, Campisi T, Moritz EK, Yaryura-Tobias JA. Body dysmorphic disorder: A preliminary evaluation of treatment and maintenance using exposure with response prevention. Behaviour Research and Therapy. 1997;**35**(1):67-70. DOI: 10.1016/S0005-7967(96)00082-4

[64] Geremia GM, Neziroglu F. Cognitive therapy in the treatment of body dysmorphic disorder. Clinical Psychology & Psychotherapy. 2001;**8**(4):243-251. DOI: 10.1002/cpp.284

[65] McKay D. Two-year follow-up of behavioral treatment and maintenance for body dysmorphic disorder. Behavior Modification. 1999;**23**(4):620-629. DOI: 10.1177/0145445599234006

[66] Veale D, Gournay K, Dryden W, Boocock A, Shah F, Willson R, et al. Body dysmorphic disorder. A cognitive behavioural model and pilot randomized controlled trial. Behaviour Research and Therapy. 1996;**34**(9):717-729

[67] Vashi NA. Beauty and Body Dysmorphic Disorder: A Clinician's Guide. New York: Springer; 2015. DOI: 10.1007/978-3-319-17867-7

[68] Sarwer DB, Gibbons LM, Crerand CE. Treating body dysmorphic disorder with cognitive-behaviour therapy. Psychiatric Annals. 2004;**34**:934-931

[69] Abramowitz JS, Taylor S, McKay D. Exposure-based treatment for obsessive compulsive disorder. In: Steketee G, editor. The Oxford Handbook of Obsessive Compulsive and Spectrum Disorders. New York, NY: Oxford University Press; 2012. pp. 322-364. DOI: 10.1093/oxfor dhb/9780195376210.001.0001

[70] Grant JE, Kim SW, Crow SJ. Prevalence and clinical features of body dysmorphic disorder in adolescent and adult psychiatric inpatients. The Journal of Clinical Psychiatry. 2001;**62**:517-522

**Chapter 5**

Crisis

**Abstract**

*and Mark Hansen Keffer*

cognitive behavioral therapy

reason, they are deserving of more attention.

**1. Introduction**

**65**

Using Matching "Smarts" and

*Michael Lamport Commons, Mansi Jitendra Shah*

Interest to Successfully Address

Depression Caused by Existential

This chapter outlines the background, nature, and explanations of existential crises. An unresolved existential crisis commonly causes depression. Crises occur in periods throughout the life cycle. They usually involve careers, relationships, or identity. The resolution often requires a development of a new stage of intellectual functioning, through which people can reflect on their interests and stage. The Existential Crisis Assessment measures severity of an existential crisis. A factor analysis showed the most important items in a person's existential crisis. My life, life in the universe, and relationships were the most important factors determining the severity of a person's existential crisis. The first solution is to match a person to a career. Another solution is to match one person to another. Three scales are used to match people to careers and partners: (1) decision-making measures how well a person addresses tasks of increasing difficulty; (2) perspective-taking predicts how well a person understands behavior of self and others; (3) core complexity interest scale identifies the reinforcement value of engaging. A further solution is that of cognitive behavioral therapy that can be used to both treat depression and offer training on social perspective-taking, a key ingredient to resolving one's crisis.

**Keywords:** model of hierarchical complexity, existential crisis, depression, anxiety,

Existential crises are seen as related more to periods in development rather than to stages of development. There is a main reason why existential crises are occurring more often and are increasingly difficult to resolve. The crisis is due to a constant increase in the number of choices that individuals face in modern day. For that

An existential crisis occurs when an individual questions whether their life has meaning, purpose, or value. The conflict that occurs during this exploration can lead to anxiety and depression. It is important, therefore, to develop ways to help individuals alleviate these feelings and "resolve" their existential crisis. The main purpose of this paper is to discuss the several factors that influence how adults

#### **Chapter 5**

## Using Matching "Smarts" and Interest to Successfully Address Depression Caused by Existential Crisis

*Michael Lamport Commons, Mansi Jitendra Shah and Mark Hansen Keffer*

### **Abstract**

This chapter outlines the background, nature, and explanations of existential crises. An unresolved existential crisis commonly causes depression. Crises occur in periods throughout the life cycle. They usually involve careers, relationships, or identity. The resolution often requires a development of a new stage of intellectual functioning, through which people can reflect on their interests and stage. The Existential Crisis Assessment measures severity of an existential crisis. A factor analysis showed the most important items in a person's existential crisis. My life, life in the universe, and relationships were the most important factors determining the severity of a person's existential crisis. The first solution is to match a person to a career. Another solution is to match one person to another. Three scales are used to match people to careers and partners: (1) decision-making measures how well a person addresses tasks of increasing difficulty; (2) perspective-taking predicts how well a person understands behavior of self and others; (3) core complexity interest scale identifies the reinforcement value of engaging. A further solution is that of cognitive behavioral therapy that can be used to both treat depression and offer training on social perspective-taking, a key ingredient to resolving one's crisis.

**Keywords:** model of hierarchical complexity, existential crisis, depression, anxiety, cognitive behavioral therapy

#### **1. Introduction**

Existential crises are seen as related more to periods in development rather than to stages of development. There is a main reason why existential crises are occurring more often and are increasingly difficult to resolve. The crisis is due to a constant increase in the number of choices that individuals face in modern day. For that reason, they are deserving of more attention.

An existential crisis occurs when an individual questions whether their life has meaning, purpose, or value. The conflict that occurs during this exploration can lead to anxiety and depression. It is important, therefore, to develop ways to help individuals alleviate these feelings and "resolve" their existential crisis. The main purpose of this paper is to discuss the several factors that influence how adults

respond to an existential crisis and how a crisis can be successfully addressed. These conflicts serve as a stimulus for action while an individual searches for new sources of meaning in the hopes of resolving their crisis. This chapter turns to systematic findings from different areas within the psychology in order to analyze how and why changes in behavior take place during an existential crisis.

counselors and therapists, so as to understand the severity of the crisis. The knowledge that one may be experiencing an existential crisis may push a person to resolve it by making changes in their life. The resolution of an existential crisis would likely

*Using Matching "Smarts" and Interest to Successfully Address Depression…*

Fifty participants filled out an online survey containing questions designed to

In the first factor, meaning of life, we have asked questions such as, "How often do you think about life's big question?" The highest factor loading was between 0.835 and 0.613. In the second factor, philosophy of living, we have asked questions such as "Does your work give your life a purpose?" The highest factor loading was between 0.780 and 0.514. In the third factor, relationships with partners, we have asked questions such as "How often do you change relationships?" The highest factor loading was between 0.728 and 0.668. Total percentage of the variance is

The decision-making instrument (DMI) measures the complexity of information

The DMI is based on a problem called the laundry instrument [8]. The laundry instrument is a causality task based upon Inhelder and Piaget's pendulum task [11]. The laundry instrument asked participants whether or not a piece of laundry would be clean after varying treatment. Participants are required to view a table depicting what has already happened (informational episodes) and then make predictions about what will happen in a new episode. Based on this method of construction, the DMI then consisted of tasks at the Preoperational Order 7, Primary Order 8, Concrete Order 9, Abstract Order 10, Formal Order 11, Systematic Order 12, Metasystematic Order 13, and Paradigmatic Order 14 in the MHC [7].

The perspective-taking instrument measures an employee's ability to understand social situations, at least in terms of the notion of informed consent. Employees completing the perspective-taking instrument gauge the helpfulness and quality of guidance of varied hypothetical helpers. The perspective-taking instrument, like the DMI, is an online test. It asks participants to rate on a 1–6 scale the quality of six "helper" figures' arguments in support of their specific methods of providing assistance [12]. Each helper's argument corresponds to one of the six stages in the MHC,

ranging from Primary Order 8 to Paradigmatic Order 14 (**Table 2**).

that an individual has considered in a decision-making process. Pascual-Leone referred to this as a measure of working memory [9, 10]. This assessment can be directly related to the task demands that certain jobs require of individuals as

assess the degree to which they feel that they are in an existential crisis. The questions in the existential crisis questionnaire are focused on three factors, those being (1) the meaning of life, (2) philosophy of living, and (3) relationships with

mitigate anxiety and depression.

*DOI: http://dx.doi.org/10.5772/intechopen.84337*

**3.2 The decision-making instrument**

**3.3 The perspective-taking instrument**

discussed later in (**Table 1**).

*3.1.1 Method*

partners.

*3.1.2 Results*

22.98%.

**67**

We unify the current work by extending notions of the existential crisis from something that happens during a "midlife crisis," to something that can happen at several periods in one's life: (a) the early teenage crisis [1], (b) the sophomore crisis [2], (c) the adult crisis [3], (d) the midlife crisis [4], and (e) the later-life crisis [1]. This discussion compares these crises in terms of features that are shared as well as those that are unique and also addresses possible influences.

In today's society, most people do not resolve their existential crises. Many people mishandle their crises and consequently do not resolve them. Such lack of resolution is mainly due to a lack of appreciation for the importance of resolving one's crises. Findings and discussions in this paper can serve as initial steps toward recognizing existential crises and their eventual resolutions.

#### **2. The model of hierarchical complexity**

The model of hierarchical complexity is a mathematical measurement theory [5, 6]. The model is a nonmentalistic, neo-Piagetian, and quantitative behavioraldevelopmental theory that analyzes the developmental difficulty of tasks. The model organizes task complexity. It proposes that tasks can be ordered in terms of their hierarchical complexity using an equally spaced unidimensional ordinal scale. It is used to predict the difficulty of behavioral tasks independent of domain and content.

The order of hierarchical complexity refers to the number of times that the coordinating actions must organize lower order actions. The hierarchical complexity of an action is determined by decomposing the action into the two or more simpler actions that make it up. This iterative process is done until the organization can only be carried out on a set of simple elements that are not built out of other actions. Actions at a higher order of hierarchical complexity can be described by several traits: (1) they are defined in terms of actions at the next lower order of hierarchical complexity; (2) organize and transform the lower-order actions; (3) produce organizations of lower-order actions that are new and not arbitrary, and cannot be accomplished by those lower-order actions alone.

Using the MHC, Commons and colleagues have shown that there are 17 OHCs [7]. The numbering of the orders and behavioral-developmental stages correspond with each other [8]. OHCs starting with the Preoperational Order 7, and continuing to the Paradigmatic Order 14, are relevant for adults. Because we estimate that 1.5% of individuals would be found who could successfully solve tasks at Order 13 (Metasystematic), and even fewer at Order 14 (Paradigmatic), most instruments constructed by those doing research in this area do not go beyond the metasystematic order. Only people performing at Concrete Stage 9 and above would be applying for employment.

#### **3. Instruments**

#### **3.1 Existential crisis instrument**

The existential crisis instrument was created to measure the extent to which someone is experiencing an existential crisis. This scale would be useful for

*Using Matching "Smarts" and Interest to Successfully Address Depression… DOI: http://dx.doi.org/10.5772/intechopen.84337*

counselors and therapists, so as to understand the severity of the crisis. The knowledge that one may be experiencing an existential crisis may push a person to resolve it by making changes in their life. The resolution of an existential crisis would likely mitigate anxiety and depression.

#### *3.1.1 Method*

respond to an existential crisis and how a crisis can be successfully addressed. These conflicts serve as a stimulus for action while an individual searches for new sources of meaning in the hopes of resolving their crisis. This chapter turns to systematic findings from different areas within the psychology in order to analyze how and

We unify the current work by extending notions of the existential crisis from something that happens during a "midlife crisis," to something that can happen at several periods in one's life: (a) the early teenage crisis [1], (b) the sophomore crisis [2], (c) the adult crisis [3], (d) the midlife crisis [4], and (e) the later-life crisis [1]. This discussion compares these crises in terms of features that are shared as well as

In today's society, most people do not resolve their existential crises. Many people mishandle their crises and consequently do not resolve them. Such lack of resolution is mainly due to a lack of appreciation for the importance of resolving one's crises. Findings and discussions in this paper can serve as initial steps toward

The model of hierarchical complexity is a mathematical measurement theory [5, 6]. The model is a nonmentalistic, neo-Piagetian, and quantitative behavioraldevelopmental theory that analyzes the developmental difficulty of tasks. The model organizes task complexity. It proposes that tasks can be ordered in terms of their hierarchical complexity using an equally spaced unidimensional ordinal scale. It is used to predict the difficulty of behavioral tasks independent of domain and content. The order of hierarchical complexity refers to the number of times that the coordinating actions must organize lower order actions. The hierarchical complexity of an action is determined by decomposing the action into the two or more simpler actions that make it up. This iterative process is done until the organization can only be carried out on a set of simple elements that are not built out of other actions. Actions at a higher order of hierarchical complexity can be described by several traits: (1) they are defined in terms of actions at the next lower order of hierarchical complexity; (2) organize and transform the lower-order actions; (3) produce organizations of lower-order actions that are new and not arbitrary,

Using the MHC, Commons and colleagues have shown that there are 17 OHCs [7]. The numbering of the orders and behavioral-developmental stages correspond with each other [8]. OHCs starting with the Preoperational Order 7, and continuing to the Paradigmatic Order 14, are relevant for adults. Because we estimate that 1.5% of individuals would be found who could successfully solve tasks at Order 13 (Metasystematic), and even fewer at Order 14 (Paradigmatic), most instruments

why changes in behavior take place during an existential crisis.

*Cognitive Behavioral Therapy - Theories and Applications*

those that are unique and also addresses possible influences.

recognizing existential crises and their eventual resolutions.

and cannot be accomplished by those lower-order actions alone.

constructed by those doing research in this area do not go beyond the

would be applying for employment.

**3.1 Existential crisis instrument**

**3. Instruments**

**66**

metasystematic order. Only people performing at Concrete Stage 9 and above

The existential crisis instrument was created to measure the extent to which

someone is experiencing an existential crisis. This scale would be useful for

**2. The model of hierarchical complexity**

Fifty participants filled out an online survey containing questions designed to assess the degree to which they feel that they are in an existential crisis. The questions in the existential crisis questionnaire are focused on three factors, those being (1) the meaning of life, (2) philosophy of living, and (3) relationships with partners.

#### *3.1.2 Results*

In the first factor, meaning of life, we have asked questions such as, "How often do you think about life's big question?" The highest factor loading was between 0.835 and 0.613. In the second factor, philosophy of living, we have asked questions such as "Does your work give your life a purpose?" The highest factor loading was between 0.780 and 0.514. In the third factor, relationships with partners, we have asked questions such as "How often do you change relationships?" The highest factor loading was between 0.728 and 0.668. Total percentage of the variance is 22.98%.

#### **3.2 The decision-making instrument**

The decision-making instrument (DMI) measures the complexity of information that an individual has considered in a decision-making process. Pascual-Leone referred to this as a measure of working memory [9, 10]. This assessment can be directly related to the task demands that certain jobs require of individuals as discussed later in (**Table 1**).

The DMI is based on a problem called the laundry instrument [8]. The laundry instrument is a causality task based upon Inhelder and Piaget's pendulum task [11]. The laundry instrument asked participants whether or not a piece of laundry would be clean after varying treatment. Participants are required to view a table depicting what has already happened (informational episodes) and then make predictions about what will happen in a new episode. Based on this method of construction, the DMI then consisted of tasks at the Preoperational Order 7, Primary Order 8, Concrete Order 9, Abstract Order 10, Formal Order 11, Systematic Order 12, Metasystematic Order 13, and Paradigmatic Order 14 in the MHC [7].

#### **3.3 The perspective-taking instrument**

The perspective-taking instrument measures an employee's ability to understand social situations, at least in terms of the notion of informed consent. Employees completing the perspective-taking instrument gauge the helpfulness and quality of guidance of varied hypothetical helpers. The perspective-taking instrument, like the DMI, is an online test. It asks participants to rate on a 1–6 scale the quality of six "helper" figures' arguments in support of their specific methods of providing assistance [12]. Each helper's argument corresponds to one of the six stages in the MHC, ranging from Primary Order 8 to Paradigmatic Order 14 (**Table 2**).

#### *Cognitive Behavioral Therapy - Theories and Applications*


are as follows: realistic, investigative, artistic, social, enterprising, and conventional. The behavioral interest assessment interest test is much shorter than the Holland. The items are more clearly written in terms of task or activity preferences. It also

8-Primary Individuals appear immature in social settings and take the view of the manager even

9-Concrete Individuals lack social grace but can negotiate and bargain effectively with some

11-Formal Individuals can revise social norms based on evidence or logical reasons. They

effectively deal with customers, employees, and the public.

managers, stockholders, and the public.

12-Systematic Individuals balance competing concerns and regulations and make judgments when

10-Abstract Individuals understand social norms, easily imitate what other people do, have good

manners, and are good at maintaining social harmony and pleasing others. They accept the company culture from a social norm's point of view and adopt professional

understand social norms and can understand when a manager is needed to make a

there are multiple concerns and conflicting policies. They may supervise relatively large single units, such as one department. They understand unintended consequences and may adjust policies to deal with them. They understand how to coordinate the different roles of people in the organization, particularly in one department, in a flexible manner to meet the short- and long-term needs. They can

Individuals take the perspective of the various stakeholders including employees,

Individual sees that there are no perfect solutions but only partial ones. They involve all the stakeholders in negotiations to try to reach a consensus as to what to sacrifice. They ask each stakeholder to represent themselves realizing that no one else can do this. That is the way they come up with a way of dealing with conflicting claims and

though it is possible for them to take their own view.

*Using Matching "Smarts" and Interest to Successfully Address Depression…*

standards as they see them modeled or as taught.

Aaron T. Beck's cognitive theory of depression proposes that persons susceptible

Cognitive behavioral therapy (CBT) aims to change our thought patterns, the beliefs we may or may not know we hold, and our attitudes and further helps us to more effectively strive toward our goals. In CBT, clients are taught cognitive and behavioral skills so they can develop more accurate/helpful beliefs and eventually become their own therapists. The beliefs that will be addressed in this chapter are

to depression develop inaccurate core beliefs about themselves, others, and the world as a result of their learning histories. These beliefs can be dormant for extended periods of time and are activated by life events that carry specific meaning for that person. Core beliefs that render someone susceptible to depression are broadly categorized into beliefs about being unlovable, worthless, helpless, and incompetent. Cognitive theory also focuses on information processing deficits,

uses a 6-point scale rather than a 2-point scale [14].

**Stage Perspective-taking**

guidance.

*DOI: http://dx.doi.org/10.5772/intechopen.84337*

decision.

priorities.

13-

14- Paradigmatic

**Table 2.**

**69**

Metasystematic

*The perspective-taking behaviors.*

**4. Cognitive behavioral therapy and depression**

selective attention, and memory biases toward the negative.

about who the person is in terms of their "smarts" and their interests.

Cognitive behavioral therapy can help treat depression in multiple ways. Depression is an episode of sadness or apathy along with other symptoms that lasts

**Table 1.** *Decision-making behaviors.*

#### **3.4 The core complexity interest scale**

The fourth instrument used to job match is a new behavioral version of the interest test that is based on Holland's interest scale [13]. Our behavioral version is based on Holland's finding that people's "interests" have six different factors. These *Using Matching "Smarts" and Interest to Successfully Address Depression… DOI: http://dx.doi.org/10.5772/intechopen.84337*


**Table 2.** *The perspective-taking behaviors.*

are as follows: realistic, investigative, artistic, social, enterprising, and conventional. The behavioral interest assessment interest test is much shorter than the Holland. The items are more clearly written in terms of task or activity preferences. It also uses a 6-point scale rather than a 2-point scale [14].

#### **4. Cognitive behavioral therapy and depression**

Aaron T. Beck's cognitive theory of depression proposes that persons susceptible to depression develop inaccurate core beliefs about themselves, others, and the world as a result of their learning histories. These beliefs can be dormant for extended periods of time and are activated by life events that carry specific meaning for that person. Core beliefs that render someone susceptible to depression are broadly categorized into beliefs about being unlovable, worthless, helpless, and incompetent. Cognitive theory also focuses on information processing deficits, selective attention, and memory biases toward the negative.

Cognitive behavioral therapy (CBT) aims to change our thought patterns, the beliefs we may or may not know we hold, and our attitudes and further helps us to more effectively strive toward our goals. In CBT, clients are taught cognitive and behavioral skills so they can develop more accurate/helpful beliefs and eventually become their own therapists. The beliefs that will be addressed in this chapter are about who the person is in terms of their "smarts" and their interests.

Cognitive behavioral therapy can help treat depression in multiple ways. Depression is an episode of sadness or apathy along with other symptoms that lasts

**3.4 The core complexity interest scale**

13-

14- Paradigmatic

**Table 1.**

**68**

*Decision-making behaviors.*

Metasystematic

**Stage Decision-making**

moderately short period of time.

*Cognitive Behavioral Therapy - Theories and Applications*

a moderate amount of time.

that follow a format.

8-Primary An individual's reasoning skills are low. At the primary stage, an individual can follow

9-Concrete An individual's reasoning skills are low. At the concrete stage, one must be given

10-Abstract An individual's reasoning skills are average. At the abstract stage, one follows

can work all day but need to be supervised a lot at first.

supervise may be used as a measure of success.

marketing, accounting, and any other necessary teams.

11-Formal An individual's reasoning skills are average. At the formal stage, one can carry out

12-Systematic An individual's developmental stage is high. At the systematic stage, one can be given

very clear and simple instructions but rely heavily on authority figures such as their managers to guide their actions and choices. The tasks they can handle must be simple and straightforward, such as stacking boxes, sweeping an area, and stocking a shelf. They can make simple logical deduction and can work unsupervised for only a

instructions but can make choices based on explicit guidelines. The tasks given can require various skills as long as guidelines are given. They can work unsupervised for

instructions in a logical fashion of clearly stated policies. This individual is capable of making decisions based on empirical or logical evidence. They can work with one causal or predictive variable at a time. This translates to carrying out a single objective that is part of the greater whole, for example, solving one-dimensional problems, calculating interest rates, collecting marketing data, and writing reports

instruction regarding goals without the need to dictate how the specific goals and objectives should be reached. They balance competing concerns and regulations and make judgments when there are multiple concerns and conflicting policies. They may supervise relatively large single units, such as one department. They understand unintended consequences and may adjust policies to deal with them. They calculate risk and understand its many sources and its costs and benefits. They write relatively complex programs. They do not need regular supervision. Performance of teams they

An individual's developmental stage is high. This manager constructs multivariate systems and matrices, for example, coordinating work between engineering and design departments. They work with the amount of information necessary to manage a team. They can put together a good team and orchestrate their work with

An individual's behavioral-developmental stage is high (0.06% of population). These individuals are C-level managers and usually their own bosses. They are the innovators who institute the process, involve the stakeholders, and sell the solution. They tend to be long-term visionary thinkers regarding business models, objectives, opportunities, negotiations, external influences, and business direction in general. At this stage, they can develop operating mechanisms across multiple business lines to know and drive quarter-by-quarter performance in tune with long-term strategy.

procedures and learns social normative ways of doing things. Therefore, they understand social norms and easily imitate what other people do. This individual uses abstract notions to make their decisions, e.g., best, coolest, never, anyone, or everyone. These notions are generally not completely accurate, but at the abstract stage, they are considered very important. When reasoning about a position, they use assertions that do not include fact or logic to justify their position. At this stage, one

The fourth instrument used to job match is a new behavioral version of the interest test that is based on Holland's interest scale [13]. Our behavioral version is based on Holland's finding that people's "interests" have six different factors. These at least two consecutive weeks and is severe enough to interrupt daily activities. Depression is not a weakness, but it should be treated. Negative thinking can affect a person's mood, sense of self, behavior, and even physical state, while CBT can help a person learn to recognize negative patterns of thought, evaluate their validity, and replace them with healthier ways of thinking. CBT can help treat depression by doing the following:

ability to think existentially. Indeed, "it is the human psyche and his consciousness, which makes us capable of making meaning." The ability to think as an independent being not subject to ingrained evolutionary instincts allows for the consequential ability not only to make decisions for oneself but also to question one's existence through introspection. "Rooted in the work of early philosophers such as Sartre, Kierkegaard, Heidegger, and Nietzsche, existentialism came about as an approach

These crises occur not as stages of development but as periods of one's life. The

Furthermore, the resolution of a crisis earlier in life does not guarantee the lack of existential crises later. The resolution of an earlier crisis through which a person finds meaning does not guarantee that the source of meaning will remain constant in the person's life. A person's interests may change, and through a later existential crisis, they may realize the necessity of finding a new source of meaning. The experience of existential crises is natural to human development. It allows for a person to find new sources of meaning by which they can live their lives. Their

In understanding the concept of an existential crisis, the logical inquiry would be to question why is it that only recently, existential crises have been garnering more attention from the society. This attention is the result of the increased difficulty of

In finding such *true meaning* within life, a person makes a choice out of the options that are presented to them. In this sense, the existential crisis acts as a fork in the road or rather a turning point through which a person is challenged with choosing the most meaningful course of action in their life. From this understanding, it can be said the expansion of the availability of choice in the society elicits an increased difficulty in finding the correct resolution to one's existential crisis. For this paper, *availability of choice* merely means the *existence* of choice within a society. The availability itself is not to be understood as being synonymous with the *accessibility* of those available choices. Accessibility here is concerned with a person's ability to access the available choices in the society. It is with such access that the person can then choose the choice

The availability of choice as an existence of choice within the society allows for a person to consider who they are and what will work for themselves. Making good choices will result in the most meaning and satisfaction within their lives. As Bigelow writes, "each man must accept responsibility for his own becoming." People must ensure that they are appropriately taking responsibility for their lives. Indeed, "an awareness of responsibility is in itself not enough to implement personal change." One must utilize that responsibility in order to gain access to the available choices that dominate the society while recognizing the necessary further steps needed to make the correct choice which will lead to meaningful changes in

form and shape seem to be tied to age and role. The crises themselves arise at different ages and within different roles. If one crisis is experienced but not resolved, it does not mean that the crisis will last a lifetime. The crisis will likely diminish due to other factors that mask the lack of meaning within a person's life. Under such a mask, a person will not acknowledge their existential crisis until later in life when it will appear again. The mask can take the form of reinforcement. For example, in making a decision to pursue a career as bankers, these people might receive a lot of reinforcement from their job in the form of money, praise, etc. However, these people may also realize later in life, after these forms of reinforcement have worn off, that there is a lack of meaning in life which will be acknowledged through an existential crisis. In resolving their crisis, these people may decide

to addressing the fundamental questions of man's existence".

*Using Matching "Smarts" and Interest to Successfully Address Depression…*

*DOI: http://dx.doi.org/10.5772/intechopen.84337*

to be a teacher and find true meaning in their life.

occurrence cannot and should not be evaded.

resolving one's existential crisis within the modern society.

which they believe to elicit the most meaning with their lives.

one's life.

**71**


c. Being goal oriented.


CBT, combined with the abovementioned instruments, is a very effective way to help people through their existential crises and treat depression. We can get a score from the instruments which can allow us to determine what specifically is causing the depression, especially among an unresolved existential crisis. The instruments also reveal the severity of the existential crisis. With the help of all these scores, one treats the depression more successfully.

If someone is struggling with an existential crisis, a recommendation that may be made is to seek cognitive behavioral therapy. In therapy, a clinician may consider contextual circumstances. They may offer specific perspectives that may help the individual to resolve their crisis. The person might work with a guidance counselor or career counselor to see which careers, their interests, and smarts match. Through matching, an individual can attain results through taking all three of the previously mentioned matching instruments. These results may help to guide the individual.

It is important to note that the matching instruments do not consider contextual circumstances. These would include but not be limited to loss of loved one, end of a relationship, and loss of job. Therefore, it is necessary that the individual reconsiders their circumstances with regard to their results and how best to proceed in the choice-making which they will face in resolving their existential crisis. Indeed, matching is not designed to offer instructions for a person to follow exactly. It is only there to help guide a person better as they continue to introspect. Merely choosing the career that is best matched according to the three instruments does not guarantee a resolution to one's crisis.

#### **5. The nature of existential crises**

To live existentially is to question life's meaning: van Deurzen-Smith writes that "Existential thinking is an attempt to think about everyday human reality in order to make sense of it, and is probably as old as the human ability to reflect" [15]. From this, it can therefore be inferred that the ability to achieve consciousness elicits the

#### *Using Matching "Smarts" and Interest to Successfully Address Depression… DOI: http://dx.doi.org/10.5772/intechopen.84337*

ability to think existentially. Indeed, "it is the human psyche and his consciousness, which makes us capable of making meaning." The ability to think as an independent being not subject to ingrained evolutionary instincts allows for the consequential ability not only to make decisions for oneself but also to question one's existence through introspection. "Rooted in the work of early philosophers such as Sartre, Kierkegaard, Heidegger, and Nietzsche, existentialism came about as an approach to addressing the fundamental questions of man's existence".

These crises occur not as stages of development but as periods of one's life. The form and shape seem to be tied to age and role. The crises themselves arise at different ages and within different roles. If one crisis is experienced but not resolved, it does not mean that the crisis will last a lifetime. The crisis will likely diminish due to other factors that mask the lack of meaning within a person's life. Under such a mask, a person will not acknowledge their existential crisis until later in life when it will appear again. The mask can take the form of reinforcement. For example, in making a decision to pursue a career as bankers, these people might receive a lot of reinforcement from their job in the form of money, praise, etc. However, these people may also realize later in life, after these forms of reinforcement have worn off, that there is a lack of meaning in life which will be acknowledged through an existential crisis. In resolving their crisis, these people may decide to be a teacher and find true meaning in their life.

Furthermore, the resolution of a crisis earlier in life does not guarantee the lack of existential crises later. The resolution of an earlier crisis through which a person finds meaning does not guarantee that the source of meaning will remain constant in the person's life. A person's interests may change, and through a later existential crisis, they may realize the necessity of finding a new source of meaning. The experience of existential crises is natural to human development. It allows for a person to find new sources of meaning by which they can live their lives. Their occurrence cannot and should not be evaded.

In understanding the concept of an existential crisis, the logical inquiry would be to question why is it that only recently, existential crises have been garnering more attention from the society. This attention is the result of the increased difficulty of resolving one's existential crisis within the modern society.

In finding such *true meaning* within life, a person makes a choice out of the options that are presented to them. In this sense, the existential crisis acts as a fork in the road or rather a turning point through which a person is challenged with choosing the most meaningful course of action in their life. From this understanding, it can be said the expansion of the availability of choice in the society elicits an increased difficulty in finding the correct resolution to one's existential crisis. For this paper, *availability of choice* merely means the *existence* of choice within a society. The availability itself is not to be understood as being synonymous with the *accessibility* of those available choices. Accessibility here is concerned with a person's ability to access the available choices in the society. It is with such access that the person can then choose the choice which they believe to elicit the most meaning with their lives.

The availability of choice as an existence of choice within the society allows for a person to consider who they are and what will work for themselves. Making good choices will result in the most meaning and satisfaction within their lives. As Bigelow writes, "each man must accept responsibility for his own becoming." People must ensure that they are appropriately taking responsibility for their lives. Indeed, "an awareness of responsibility is in itself not enough to implement personal change." One must utilize that responsibility in order to gain access to the available choices that dominate the society while recognizing the necessary further steps needed to make the correct choice which will lead to meaningful changes in one's life.

at least two consecutive weeks and is severe enough to interrupt daily activities. Depression is not a weakness, but it should be treated. Negative thinking can affect a person's mood, sense of self, behavior, and even physical state, while CBT can help a person learn to recognize negative patterns of thought, evaluate their validity, and replace them with healthier ways of thinking. CBT can help treat depression by

a. Utilizing cognitive restructuring and focusing on the immediate present.

e. Making sure patients take an active role in their learning, in sessions, and

f. Employing multiple strategies such as role playing, imaging, guided discovery,

g.CBT makes it possible to face conflicts and explore possibilities more directly.

CBT, combined with the abovementioned instruments, is a very effective way to help people through their existential crises and treat depression. We can get a score from the instruments which can allow us to determine what specifically is causing the depression, especially among an unresolved existential crisis. The instruments also reveal the severity of the existential crisis. With the help of all these scores, one

If someone is struggling with an existential crisis, a recommendation that may be made is to seek cognitive behavioral therapy. In therapy, a clinician may consider contextual circumstances. They may offer specific perspectives that may help the individual to resolve their crisis. The person might work with a guidance counselor or career counselor to see which careers, their interests, and smarts match. Through matching, an individual can attain results through taking all three of the previously mentioned matching instruments. These results may help to guide the individual. It is important to note that the matching instruments do not consider contextual circumstances. These would include but not be limited to loss of loved one, end of a relationship, and loss of job. Therefore, it is necessary that the individual reconsiders their circumstances with regard to their results and how best to proceed in the choice-making which they will face in resolving their existential crisis. Indeed, matching is not designed to offer instructions for a person to follow exactly. It is only there to help guide a person better as they continue to introspect. Merely choosing the career that is best matched according to the three instruments does not

To live existentially is to question life's meaning: van Deurzen-Smith writes that "Existential thinking is an attempt to think about everyday human reality in order to make sense of it, and is probably as old as the human ability to reflect" [15]. From this, it can therefore be inferred that the ability to achieve consciousness elicits the

b.Focusing on specific problems in individual or group sessions.

d.Taking an educational approach to teach patients ways to cope.

between sessions using homework assignments.

*Cognitive Behavioral Therapy - Theories and Applications*

doing the following:

c. Being goal oriented.

and behavioral experiments.

treats the depression more successfully.

guarantee a resolution to one's crisis.

**5. The nature of existential crises**

**70**

The resulting anxiety of having to make such a choice is best understood using Barry Schwartz's law: "As the number of options increases, the costs, in time and effort, of gathering the information needed to make a good choice also increase."

school, the kinds of jobs they have access to the kinds of friends they make." Each of these things determines and defines a person's privilege as related to his or her level

These people seem to be caught in a viscous cycle, though which their limited accessibility to choice earlier in life systematically maintains their low socioeconomic status, thereby both maintaining their little accessibility to choice later in their life and extending the cycle to their children. It can be said that greater accessibility to choice correlates with higher likelihood of attaining wealth, and it is wealth that typically grants a person access to *choice.* Without choice, people will have little opportunity to find meaning in their life even though they have the freedom to do so. Indeed, the possibility to find meaning for such people is dra-

The viscous cycle which limited accessibility to choice creates emphasizes the importance of true equal opportunity in the USA. This equal opportunity can only be achieved through a fair distribution of wealth across the USA, distribution that will provide opportunities for every American to lead a meaningful life. It is this misdistribution of wealth that is at the root of racism in the USA, as pointed out by Anderson: "True racism exists only when one group holds a disproportionate share of wealth and power over another group then uses those resources to marginalize,

With the assumption of full accessibility to choice, in order to have a better understanding of the details of existential crises, it is important to consider the main aspects of each crisis. There are at least five existential crises that all revolve around the theme of choice: the early teenage crisis, the sophomore crisis, the adult crisis,

The early teenage crisis is concerned with, as suggested by Fitzgerald, one of the "greatest of life's tasks: the breaking away from the protection of others to find and define oneself" [19]. Through this breaking away, it is likely that a teenager will seek a form of individuality by changing their behaviors as well as their personalities. Through such redefinitions, teenagers change their behaviors as well as their personalities. These changes are a part of the developmental transition from childhood to adulthood developing organisms that must attain the necessary skills for independence. However, contrary to a common belief, hormones have been shown to have little effect on this developmental transition. Indeed, "gonadal hormones, have been shown to account for only a small amount of the variance in behavior during adolescence" [20]. The developmental transition and the attributed changes are rather linked to the teenager's learning of independence. This learning is reinforced by the levels of peer interaction which dominate the teenager's life: "During an average week during the academic year, adolescents have been reported to spend close to one-third of normal waking hours talking with peers, but only 8% of this time talking with adult. These outside-the-home relationships help to ease

The relationships themselves facilitate the behavioral change during adolescence. In understanding this, the reason for rebellious behavior becomes clear. "As noted peer interactions may also in some cases facilitate antisocial behavior, with peer conformity to antisocial behaviors including cheating, stealing, trespassing,

Hence, little accessibility to choice is greatly significant in the scope of its limitation on the freedom of choice. Indeed, outside of luck and individual circumstances, in most cases, it is only through such access that a person can even have a

of accessibility to the availability of choice within the USA.

*Using Matching "Smarts" and Interest to Successfully Address Depression…*

matically limited by diminished accessibility to choice.

exploit, exclude and subordinate the weaker group" [18].

the transition toward independence from the family" [20].

the midlife crisis, and the later-life crisis.

**5.1 The early teenage crisis**

**73**

chance at resolving their existential crisis.

*DOI: http://dx.doi.org/10.5772/intechopen.84337*

Choice has always existed among the human society but only really started to dominate the society in the form of career choice during the Renaissance period during which urbanization took place. Such urbanization created more options within the scope of careers for wider populations. Indeed, "although nobles and the wealthy largely worked in the same occupations they had during the Middle Ages, increased urbanization expanded roles for women and the emerging middle class."

Due to the middle class being a small portion of the population during this time, it was still common for most sons to merely take over the businesses of their fathers, thereby involving little introspection. It was only during the industrial age that existential crises, as a consequence of further choice, began to occur more frequently. This expansion of choice is shown by the fact that "during the Industrial Revolution, due to the technological improvement, new jobs were created which lead to more job opportunities, thus emerged the middle classes."

This further availability of choice resulted in the pursuit by people to find a job through which they could experience the most meaning in their lives. In seeking such a job, these people would face an existential crisis in which they would reflect on all of the options available to them. It was a time of opportunity for people to find meaning that personally matched their individual lives. The commonality of sons merely taking over the businesses of their fathers was diminishing in place of further introspection performed by the growing middle class. Now, such availability of choice is inescapable. For example, high school and university, particularly in the USA, are structured so that people are constantly presented with different areas of study and interest, leading people into existential crises through which they must not only select a career but also discover who they are as an individual.

Such availability of choice within the US society increases the potential difficulty of the process by which an individual resolves their existential crises, due to the challenge of not only having to access the available choices in the society but also having to sift through all of the choices once they are accessed. The mere knowledge of there being an increased availability of choice in one's society makes that person's existential crisis more difficult especially if those choices are not readily accessible with ease.

Indeed, though everyone in the USA will face similar difficulty of shifting through the available choice, depending on the number of interests, as established by Schwartz's law, the route by which availability of choice is accessed is very much differentiated, usually by class, in terms of difficulty between different people [16]. Not everyone shares the same privilege of being able to make a choice without any struggle of attaining the means to make that choice. Such privilege increases the likelihood of finding the correct path that will elicit the most meaning in one's life due to the ease of accessing choice associated with that privilege.

Though such privileged, people may struggle as they attempt to make the correct choice. Their struggle will not compare to the additional struggle that a person may face in trying to gain access to an availability of choice. Bigelow references Kierkegaard, stating that "we encounter the true self in the involvement and agony of choice and in the pathos of commitment to our choice" [17]. It is only through the experience of that *agony of choice* that people can find the choices in their life that elicit the most meaning.

The additional struggle of gaining access to such agony is noticeable with regard to the differentiated accessibility of choice between the poor and the wealthy. This differentiation is explained by the fact that "class affects whether someone is going to be accepted into a particular kind of school, their likelihood of succeeding in that

#### *Using Matching "Smarts" and Interest to Successfully Address Depression… DOI: http://dx.doi.org/10.5772/intechopen.84337*

school, the kinds of jobs they have access to the kinds of friends they make." Each of these things determines and defines a person's privilege as related to his or her level of accessibility to the availability of choice within the USA.

Hence, little accessibility to choice is greatly significant in the scope of its limitation on the freedom of choice. Indeed, outside of luck and individual circumstances, in most cases, it is only through such access that a person can even have a chance at resolving their existential crisis.

These people seem to be caught in a viscous cycle, though which their limited accessibility to choice earlier in life systematically maintains their low socioeconomic status, thereby both maintaining their little accessibility to choice later in their life and extending the cycle to their children. It can be said that greater accessibility to choice correlates with higher likelihood of attaining wealth, and it is wealth that typically grants a person access to *choice.* Without choice, people will have little opportunity to find meaning in their life even though they have the freedom to do so. Indeed, the possibility to find meaning for such people is dramatically limited by diminished accessibility to choice.

The viscous cycle which limited accessibility to choice creates emphasizes the importance of true equal opportunity in the USA. This equal opportunity can only be achieved through a fair distribution of wealth across the USA, distribution that will provide opportunities for every American to lead a meaningful life. It is this misdistribution of wealth that is at the root of racism in the USA, as pointed out by Anderson: "True racism exists only when one group holds a disproportionate share of wealth and power over another group then uses those resources to marginalize, exploit, exclude and subordinate the weaker group" [18].

With the assumption of full accessibility to choice, in order to have a better understanding of the details of existential crises, it is important to consider the main aspects of each crisis. There are at least five existential crises that all revolve around the theme of choice: the early teenage crisis, the sophomore crisis, the adult crisis, the midlife crisis, and the later-life crisis.

#### **5.1 The early teenage crisis**

The resulting anxiety of having to make such a choice is best understood using Barry Schwartz's law: "As the number of options increases, the costs, in time and effort, of gathering the information needed to make a good choice also increase." Choice has always existed among the human society but only really started to dominate the society in the form of career choice during the Renaissance period during which urbanization took place. Such urbanization created more options within the scope of careers for wider populations. Indeed, "although nobles and the wealthy largely worked in the same occupations they had during the Middle Ages, increased urbanization expanded roles for women and the emerging middle class." Due to the middle class being a small portion of the population during this time, it was still common for most sons to merely take over the businesses of their fathers, thereby involving little introspection. It was only during the industrial age that existential crises, as a consequence of further choice, began to occur more frequently. This expansion of choice is shown by the fact that "during the Industrial Revolution, due to the technological improvement, new jobs were created which

This further availability of choice resulted in the pursuit by people to find a job through which they could experience the most meaning in their lives. In seeking such a job, these people would face an existential crisis in which they would reflect on all of the options available to them. It was a time of opportunity for people to find meaning that personally matched their individual lives. The commonality of sons merely taking over the businesses of their fathers was diminishing in place of further introspection performed by the growing middle class. Now, such availability of choice is inescapable. For example, high school and university, particularly in the USA, are structured so that people are constantly presented with different areas of study and interest, leading people into existential crises through which they must

Such availability of choice within the US society increases the potential difficulty of the process by which an individual resolves their existential crises, due to the challenge of not only having to access the available choices in the society but also having to sift through all of the choices once they are accessed. The mere knowledge of there being an increased availability of choice in one's society makes that person's existential crisis more difficult especially if those choices are not readily accessible

Indeed, though everyone in the USA will face similar difficulty of shifting through the available choice, depending on the number of interests, as established by Schwartz's law, the route by which availability of choice is accessed is very much differentiated, usually by class, in terms of difficulty between different people [16]. Not everyone shares the same privilege of being able to make a choice without any struggle of attaining the means to make that choice. Such privilege increases the likelihood of finding the correct path that will elicit the most meaning in one's life

Though such privileged, people may struggle as they attempt to make the correct choice. Their struggle will not compare to the additional struggle that a person may face in trying to gain access to an availability of choice. Bigelow references Kierkegaard, stating that "we encounter the true self in the involvement and agony of choice and in the pathos of commitment to our choice" [17]. It is only through the experience of that *agony of choice* that people can find the choices in their life that

The additional struggle of gaining access to such agony is noticeable with regard to the differentiated accessibility of choice between the poor and the wealthy. This differentiation is explained by the fact that "class affects whether someone is going to be accepted into a particular kind of school, their likelihood of succeeding in that

lead to more job opportunities, thus emerged the middle classes."

*Cognitive Behavioral Therapy - Theories and Applications*

not only select a career but also discover who they are as an individual.

due to the ease of accessing choice associated with that privilege.

with ease.

elicit the most meaning.

**72**

The early teenage crisis is concerned with, as suggested by Fitzgerald, one of the "greatest of life's tasks: the breaking away from the protection of others to find and define oneself" [19]. Through this breaking away, it is likely that a teenager will seek a form of individuality by changing their behaviors as well as their personalities. Through such redefinitions, teenagers change their behaviors as well as their personalities. These changes are a part of the developmental transition from childhood to adulthood developing organisms that must attain the necessary skills for independence. However, contrary to a common belief, hormones have been shown to have little effect on this developmental transition. Indeed, "gonadal hormones, have been shown to account for only a small amount of the variance in behavior during adolescence" [20]. The developmental transition and the attributed changes are rather linked to the teenager's learning of independence. This learning is reinforced by the levels of peer interaction which dominate the teenager's life: "During an average week during the academic year, adolescents have been reported to spend close to one-third of normal waking hours talking with peers, but only 8% of this time talking with adult. These outside-the-home relationships help to ease the transition toward independence from the family" [20].

The relationships themselves facilitate the behavioral change during adolescence. In understanding this, the reason for rebellious behavior becomes clear. "As noted peer interactions may also in some cases facilitate antisocial behavior, with peer conformity to antisocial behaviors including cheating, stealing, trespassing,

and minor property destruction peaking in early- to mid-adolescence." What is important to note here is the idea of *conformity*. In seeking to find independence from one's parents, a teenager will likely conform to the behaviors that define their peer groups, typically one variable at a time. It is important to note that due to media, such conformity is not only influenced by peers but also by celebrities.

**5.2 The sophomore crisis**

*DOI: http://dx.doi.org/10.5772/intechopen.84337*

interconnectivity of the Internet age.

which may turn out to be correct.

**5.3 The adult crisis**

**75**

This is the first existential crisis through which an individual begins to question the meaning of their life and how to find such meaning. It occurs during one's late teens or early 20s as evidenced by William Perry's "model for intellectual development in college students" [2]. The final stage of intellectual development, according to Perry, is *commitment*. It is the "integration of knowledge from other sources with personal experience and reflection; students make commitment to values that mat-

It is such commitment that is arguably required in order to resolve the sophomore crisis, commitment to one's personal sources of meaning. Furthermore, the sophomore crisis is related to the existential questions which Erikson poses: "Who am I? Who can I be?" These questions are the focus of a young adult's thoughts in relation to choice of career during the sophomore crisis [1]. Erikson writes that these questions occur from 12 to 18 years of age. However, this is likely an outdated range due to the recent influx of choices career-wise available to students caused by

As Schwartz says, more choices will result in further anxiety over the difficulty of making the correct choice [16]. This difficulty requires an older age in order to sift through the many choices in career that are available to the young adult. The sophomore crisis is best understood as being rooted in anxiety over one's future and ability to optimally perform while delivering one's best intellectual capabilities. Such anxiety is typically the driving force behind wanting to resolve the sophomore

If this crisis is recognized yet unresolved, the individual can find themselves feeling lost and panicked, feelings which eventually result in depression caused by the inability to find meaning within life. Indeed, the sophomore crisis is a major source of adolescent depression in today's society. It is important to note that some people may not suffer through this crisis if they have already decided for themselves what they want to do with the rest of their lives at an early age. These decisions, instead of being informed ones, are rather poorly grounded guesses

By *poorly grounded*, what is meant is that these guesses are typically based not on one's personal interest but rather on those of others. For example, young children may base their career choice on that of their parents or even their idols. In doing so, these children may grow older never considering their own personal interests, merely relying on essentially a *bet* that their guess was correct. In some cases, these bets turn out to be correct, and a person can fully avoid a sophomore crisis having

However, if these guesses turn out to be wrong, which they often do, the person will face the sophomore crisis, likely with a heightened level of suffering. Such extended suffering would be the result of the individual's profound lack of introspection with regard to their own interests in potential careers before the sophomore crisis. It is therefore important not to solely rely on the guess which one might make as a child but rather explore one's identity so as to establish for oneself if that guess aligns with one's interests. Indeed, only through introspection and reflection over one's interests in potential careers can a person resolve their sophomore crisis, establishing for themselves the correct career path from which the most meaning in their life can be derived.

This existential crisis occurs during a person's mid- to late 20s and is similar to the sophomore crisis in that it is concerned with making choices as to who you want

already resolved for themselves what will elicit meaning in their lives.

ter to them and learn to take responsibility for committed beliefs."

*Using Matching "Smarts" and Interest to Successfully Address Depression…*

crisis so as to establish one's identity as defined by a career.

A celebrity's behavior and decisions will likely affect a teenager's choice of behavior and decisions. Indeed, a teenager will likely conform to the actions of the celebrity, therefore highlighting the importance of responsibility in celebrities whom teenagers idolize. For example, more and more in today's society, younger teenagers are sexualizing their clothing and appearance as part of their conformity to celebrities'self-presentations. It can therefore be said that depending on what is valued by either celebrities or peers, a teenager will likely conform to these values.

The reason for this conformity is more than mere consequence of peer pressure to *fit in* according to the highest-held values, whether those values be peer or celebrity related. The reason can be extended to the idea that as teenagers' developmentally transition, they displace their dependence on the behavioral values held by their parents and other adults with further dependence on those values held by one's peers or idolized celebrities for the sake of comfort. One article points this out in writing that "It is possible that this heightened conformity to peer pressure during early adolescence is a sign of a sort of emotional 'way station' between becoming emotionally autonomous from parents and becoming a genuinely autonomous person…the adolescent may become emotionally autonomous from parents before he or she is emotionally ready for this degree of independence and may turn to peers to fill this void."

Dependence on one's parents is all the teenager will have known before having their time dominated by peer relationships. Consequently, being dependent on one's peers will be the comfortable route of action for the teenager. However, after constantly changing their behaviors according to the current peer-held behavioral values, it is likely that teenagers will desire a form of independence defined by individuality. One study finds that "resistance to peer influence increases linearly over the course of adolescence, especially between ages 14 and 18." This resistance would be the result of pursuing independence. This pursuit is emblematic of a teenager experiencing their early teenage crisis in which they acknowledge their lack of independence and individuality.

Through this crisis, the teenager will gradually distance themselves from the broken amalgamation of peer values which used to define their identity. The teenager will be challenged by having to find the correct resolution to their crisis through which they can define their own personal values, independence, and individuality. Fitzgerald suggested "succumbing to the external pressures of conformity and meanings that are thrust upon one by objects or circumstances encountered in the environment it is solely up to the individual in order to create meaning and purpose in life" [19]. However, if such meaning and purpose is not created, the early teenage crisis will not be resolved, likely resulting in the teenager feeling lost in their identity. Such teenagers will likely experience depression, a side effect which is further discussed later.

Depression at this vulnerable age can have extreme consequences such as suicide. It is therefore very important that the early teenage crisis is resolved. The nature of the crisis and its resolution can be discussed developmentally in terms of resistance to peer pressure: "the growth of resistance to peer influence is a developmental phenomenon bounded by individuation from parents at its onset and by the development of a sense of identity at its conclusion." Indeed, achieving a sense of identity through independence is the goal of the early teenage crisis.

*Using Matching "Smarts" and Interest to Successfully Address Depression… DOI: http://dx.doi.org/10.5772/intechopen.84337*

#### **5.2 The sophomore crisis**

and minor property destruction peaking in early- to mid-adolescence." What is important to note here is the idea of *conformity*. In seeking to find independence from one's parents, a teenager will likely conform to the behaviors that define their peer groups, typically one variable at a time. It is important to note that due to media, such conformity is not only influenced by peers but also by celebrities. A celebrity's behavior and decisions will likely affect a teenager's choice of behavior and decisions. Indeed, a teenager will likely conform to the actions of the celebrity, therefore highlighting the importance of responsibility in celebrities whom teenagers idolize. For example, more and more in today's society, younger teenagers are sexualizing their clothing and appearance as part of their conformity

*Cognitive Behavioral Therapy - Theories and Applications*

to celebrities'self-presentations. It can therefore be said that depending on

to *fit in* according to the highest-held values, whether those values be peer or celebrity related. The reason can be extended to the idea that as teenagers' developmentally transition, they displace their dependence on the behavioral values held by their parents and other adults with further dependence on those values held by one's peers or idolized celebrities for the sake of comfort. One article points this out in writing that "It is possible that this heightened conformity to peer pressure during early adolescence is a sign of a sort of emotional 'way station' between becoming emotionally autonomous from parents and becoming a genuinely autonomous person…the adolescent may become emotionally autonomous from parents before he or she is emotionally ready for this degree of independence and may turn

values.

to peers to fill this void."

lack of independence and individuality.

which is further discussed later.

**74**

what is valued by either celebrities or peers, a teenager will likely conform to these

The reason for this conformity is more than mere consequence of peer pressure

Dependence on one's parents is all the teenager will have known before having their time dominated by peer relationships. Consequently, being dependent on one's peers will be the comfortable route of action for the teenager. However, after constantly changing their behaviors according to the current peer-held behavioral values, it is likely that teenagers will desire a form of independence defined by individuality. One study finds that "resistance to peer influence increases linearly over the course of adolescence, especially between ages 14 and 18." This resistance would be the result of pursuing independence. This pursuit is emblematic of a teenager experiencing their early teenage crisis in which they acknowledge their

Through this crisis, the teenager will gradually distance themselves from the broken amalgamation of peer values which used to define their identity. The teenager will be challenged by having to find the correct resolution to their crisis through which they can define their own personal values, independence, and individuality. Fitzgerald suggested "succumbing to the external pressures of conformity and meanings that are thrust upon one by objects or circumstances encountered in the environment it is solely up to the individual in order to create meaning and purpose in life" [19]. However, if such meaning and purpose is not created, the early teenage crisis will not be resolved, likely resulting in the teenager feeling lost in their identity. Such teenagers will likely experience depression, a side effect

Depression at this vulnerable age can have extreme consequences such as suicide. It is therefore very important that the early teenage crisis is resolved. The nature of the crisis and its resolution can be discussed developmentally in terms of resistance to peer pressure: "the growth of resistance to peer influence is a developmental phenomenon bounded by individuation from parents at its onset and by the development of a sense of identity at its conclusion." Indeed, achieving a sense of

identity through independence is the goal of the early teenage crisis.

This is the first existential crisis through which an individual begins to question the meaning of their life and how to find such meaning. It occurs during one's late teens or early 20s as evidenced by William Perry's "model for intellectual development in college students" [2]. The final stage of intellectual development, according to Perry, is *commitment*. It is the "integration of knowledge from other sources with personal experience and reflection; students make commitment to values that matter to them and learn to take responsibility for committed beliefs."

It is such commitment that is arguably required in order to resolve the sophomore crisis, commitment to one's personal sources of meaning. Furthermore, the sophomore crisis is related to the existential questions which Erikson poses: "Who am I? Who can I be?" These questions are the focus of a young adult's thoughts in relation to choice of career during the sophomore crisis [1]. Erikson writes that these questions occur from 12 to 18 years of age. However, this is likely an outdated range due to the recent influx of choices career-wise available to students caused by interconnectivity of the Internet age.

As Schwartz says, more choices will result in further anxiety over the difficulty of making the correct choice [16]. This difficulty requires an older age in order to sift through the many choices in career that are available to the young adult. The sophomore crisis is best understood as being rooted in anxiety over one's future and ability to optimally perform while delivering one's best intellectual capabilities. Such anxiety is typically the driving force behind wanting to resolve the sophomore crisis so as to establish one's identity as defined by a career.

If this crisis is recognized yet unresolved, the individual can find themselves feeling lost and panicked, feelings which eventually result in depression caused by the inability to find meaning within life. Indeed, the sophomore crisis is a major source of adolescent depression in today's society. It is important to note that some people may not suffer through this crisis if they have already decided for themselves what they want to do with the rest of their lives at an early age. These decisions, instead of being informed ones, are rather poorly grounded guesses which may turn out to be correct.

By *poorly grounded*, what is meant is that these guesses are typically based not on one's personal interest but rather on those of others. For example, young children may base their career choice on that of their parents or even their idols. In doing so, these children may grow older never considering their own personal interests, merely relying on essentially a *bet* that their guess was correct. In some cases, these bets turn out to be correct, and a person can fully avoid a sophomore crisis having already resolved for themselves what will elicit meaning in their lives.

However, if these guesses turn out to be wrong, which they often do, the person will face the sophomore crisis, likely with a heightened level of suffering. Such extended suffering would be the result of the individual's profound lack of introspection with regard to their own interests in potential careers before the sophomore crisis. It is therefore important not to solely rely on the guess which one might make as a child but rather explore one's identity so as to establish for oneself if that guess aligns with one's interests. Indeed, only through introspection and reflection over one's interests in potential careers can a person resolve their sophomore crisis, establishing for themselves the correct career path from which the most meaning in their life can be derived.

#### **5.3 The adult crisis**

This existential crisis occurs during a person's mid- to late 20s and is similar to the sophomore crisis in that it is concerned with making choices as to who you want to be. Indeed, it is an extension of the existential questions posed by Erikson ("Who am I? Who Can I be?"), being more complex in nature, dealing with things other than career path [1]. It challenges the person to decide for themselves who they want to be and who they can be. In resolving this crisis, a person usually becomes comfortable with who they are in all facets of their life, whether it has to do with the choice of religion, political party, familial dedication, level of introversion or extraversion, level of attachment to others, etc.

rather merely defined as the "overload stressors in midlife." In brief, many midlife stressors simply require the individual to resolve some of the stressors so as to

A midlife crisis on the other hand is the result of reflection over life choices and the meaningfulness of those choices. As one article points out, "problems occur at the midlife transition when a person around the age of 40 perceives that personal growth has been stymied or thwarted. This distance between current achievement and aspirations arises from personal reflection at reaching a symbolic (or physical) marker of age." Within this marker of age, the individual is questioning the choices as markers of personal achievement (and meaning) that they have made in their life

The signs that reveal dissatisfaction with life choices during a mid-life crisis [21] usually revolve around career, partner, children, regrets over spent youthfulness, economic or social status, unaccomplished goals, and more. The length and struggle of the midlife crisis is therefore typically determined by whether or not earlier crises were resolved. Indeed, as one article reports, "the majority of self-perceived 'most important' turning points in life were reported as taking place in early adulthood,

Insomuch as these turning points being able to elicit meaningfulness in one's life, if they were resolved, it would be logical to conclude that the struggle of a midlife crisis, which involves reflection over the meaningfulness of one's life, would be significantly lessened. Through the resolution of earlier crises, people will generally feel fulfilled by their life choices which elicit meaningfulness upon reflecting over their life during the midlife crisis. However, it is important to note that the resolution of earlier crises does not always imply that the sources of meaning will remain

Consequently, during a midlife crisis, an individual may recognize the necessity of finding other sources of meaning. In contrast, if earlier crises were not resolved, the person will certainly suffer through regret over their life choices and inability to have found meaning in their lives. In order to resolve this crisis, many will desperately try to correct their life choices in order to find meaning. Indeed, as found in one study, "many respondents connected the midlife crisis to life events such as job loss or forced unemployment, early retirement, extramarital affairs, divorce, separation, deaths of close friends or family members, and other major life

Each of these events suggests or predicts a level of reflection over life and the meaning of one's personal life. Under this reflection, people will desire and attempt to find meaning in their life. However, many will fail, not able to deploy the energy and youthfulness that is required in order to make meaningful changes to their lives. The inability to find the desired source of meaning in one's life usually after years of attempting to do so will result in the *later-life crisis* through which a person will acknowledge the lack of meaning in their life and face depression and hopelessness.

The later-life crisis takes place toward a person's late 60s and is understood as a time of reflection. It is usually triggered by retirement, losing a job, illness, or death of peer or loved one all of which leads a person to reflect on their life choices and the meaningfulness of their life. This reflection is prompted by an awareness of the little time left in one's life. This crisis is further defined by Erikson's existential question: "Is it okay to have been me?" Within this question, Erikson writes that we engage in contemplation over whether or not we feel accomplished or satisfied with the

relieve the overbearing stress that is dominating the individual's life.

*Using Matching "Smarts" and Interest to Successfully Address Depression…*

and whether or not they regret these choices [21].

*DOI: http://dx.doi.org/10.5772/intechopen.84337*

or even adolescence."

constant throughout a person's life.

crises, such as health problems."

**5.5 The later-life crisis**

meaningfulness of our lives [1].

**77**

The list goes and is embodied by the choices by which a person defines themselves. In resolving the adult crisis, the idea is that a person becomes a fully formed, resolved, and individual adult who is comfortable with who they are as a member of the society. Along with resolving how one defines themselves, the adult crisis is concerned with becoming financially independent and performing adult roles, hence, the name, *adult crisis*. The crisis is the capstone of entering adulthood.

"The definition of adulthood that emerges from the GSS includes being financially independent, leaving home, completing school, and working full-time and further involves the acquisition of the skills and attitudes needed to perform adult roles." Interestingly, one study shows that this fulfillment of entering adulthood under this definition is achieved at a later age in today's society compared to the past generations: "The primary reason for the prolongation of early adulthood is that it takes much longer to get a full-time job that pays enough to support a family than it did in the past" [1].

This prolongation is the likely result of not only more choices in today's society but also the limited availability of jobs. As one article points out, "being a college graduate nowadays no longer offers the probability of a career." It used to be the case that in pursuing a college education, the security of a job would be mostly guaranteed. This is no longer the case and as a consequence, "In order to complete their education and begin work careers, young people now often linger in a state of 'semi-autonomy' during their 20s, combining support from their families with whatever they can make in the labor market and borrow."

The outcome of this *semiautonomy* is an inability to attain full autonomy through adulthood until much later on during one's late 20s, the peak of the adult crisis. Therefore, not only does a person need to become confident in the choices that define him or her as sources of meaning in their life through the resolution of their adult crisis, but they also need to have achieved adulthood. Not resolving this crisis can lead to feelings of disorientation and panic caused by a lack of confidence in personal identity. Ultimately, not knowing how to identify oneself in all aspects of life including your role as an adult will result in feelings of concern and depression.

#### **5.4 The midlife crisis**

This crisis in widely discussed in the media and is a household term, occurring during the early middle-age years, a variable age range. Wethington states that the midlife crisis is a term that "connotes personal turmoil and sudden changes in personal goals and lifestyle, brought about by the realization of aging, physical decline, or entrapment in unwelcome, restrictive roles" [3]. People often mistake this turmoil in life to be the result of high levels of stress. Indeed, though there is "expected stress" attributed with the midlife crisis, it is not the presence of stressors in life that causes the crisis. Indeed, there is a key difference between the midlife crisis and a "midlife stressor."

As one article points out, "common psychosocial stressors may have severe and long-standing physiological and psychological consequences." The stressor is best described as an independent variable which is viewed as stressing to the individual. The summation of these stressors is sometimes defined as a midlife crisis but is

#### *Using Matching "Smarts" and Interest to Successfully Address Depression… DOI: http://dx.doi.org/10.5772/intechopen.84337*

rather merely defined as the "overload stressors in midlife." In brief, many midlife stressors simply require the individual to resolve some of the stressors so as to relieve the overbearing stress that is dominating the individual's life.

A midlife crisis on the other hand is the result of reflection over life choices and the meaningfulness of those choices. As one article points out, "problems occur at the midlife transition when a person around the age of 40 perceives that personal growth has been stymied or thwarted. This distance between current achievement and aspirations arises from personal reflection at reaching a symbolic (or physical) marker of age." Within this marker of age, the individual is questioning the choices as markers of personal achievement (and meaning) that they have made in their life and whether or not they regret these choices [21].

The signs that reveal dissatisfaction with life choices during a mid-life crisis [21] usually revolve around career, partner, children, regrets over spent youthfulness, economic or social status, unaccomplished goals, and more. The length and struggle of the midlife crisis is therefore typically determined by whether or not earlier crises were resolved. Indeed, as one article reports, "the majority of self-perceived 'most important' turning points in life were reported as taking place in early adulthood, or even adolescence."

Insomuch as these turning points being able to elicit meaningfulness in one's life, if they were resolved, it would be logical to conclude that the struggle of a midlife crisis, which involves reflection over the meaningfulness of one's life, would be significantly lessened. Through the resolution of earlier crises, people will generally feel fulfilled by their life choices which elicit meaningfulness upon reflecting over their life during the midlife crisis. However, it is important to note that the resolution of earlier crises does not always imply that the sources of meaning will remain constant throughout a person's life.

Consequently, during a midlife crisis, an individual may recognize the necessity of finding other sources of meaning. In contrast, if earlier crises were not resolved, the person will certainly suffer through regret over their life choices and inability to have found meaning in their lives. In order to resolve this crisis, many will desperately try to correct their life choices in order to find meaning. Indeed, as found in one study, "many respondents connected the midlife crisis to life events such as job loss or forced unemployment, early retirement, extramarital affairs, divorce, separation, deaths of close friends or family members, and other major life crises, such as health problems."

Each of these events suggests or predicts a level of reflection over life and the meaning of one's personal life. Under this reflection, people will desire and attempt to find meaning in their life. However, many will fail, not able to deploy the energy and youthfulness that is required in order to make meaningful changes to their lives. The inability to find the desired source of meaning in one's life usually after years of attempting to do so will result in the *later-life crisis* through which a person will acknowledge the lack of meaning in their life and face depression and hopelessness.

#### **5.5 The later-life crisis**

The later-life crisis takes place toward a person's late 60s and is understood as a time of reflection. It is usually triggered by retirement, losing a job, illness, or death of peer or loved one all of which leads a person to reflect on their life choices and the meaningfulness of their life. This reflection is prompted by an awareness of the little time left in one's life. This crisis is further defined by Erikson's existential question: "Is it okay to have been me?" Within this question, Erikson writes that we engage in contemplation over whether or not we feel accomplished or satisfied with the meaningfulness of our lives [1].

to be. Indeed, it is an extension of the existential questions posed by Erikson ("Who am I? Who Can I be?"), being more complex in nature, dealing with things other than career path [1]. It challenges the person to decide for themselves who they want to be and who they can be. In resolving this crisis, a person usually becomes comfortable with who they are in all facets of their life, whether it has to do with the choice of religion, political party, familial dedication, level of introversion or extra-

The list goes and is embodied by the choices by which a person defines themselves. In resolving the adult crisis, the idea is that a person becomes a fully formed, resolved, and individual adult who is comfortable with who they are as a member of the society. Along with resolving how one defines themselves, the adult crisis is concerned with becoming financially independent and performing adult roles, hence, the name, *adult crisis*. The crisis is the capstone of entering adulthood. "The definition of adulthood that emerges from the GSS includes being financially independent, leaving home, completing school, and working full-time and further involves the acquisition of the skills and attitudes needed to perform adult roles." Interestingly, one study shows that this fulfillment of entering adulthood under this definition is achieved at a later age in today's society compared to the past generations: "The primary reason for the prolongation of early adulthood is that it takes much longer to get a full-time job that pays enough to support a family than it

This prolongation is the likely result of not only more choices in today's society but also the limited availability of jobs. As one article points out, "being a college graduate nowadays no longer offers the probability of a career." It used to be the case that in pursuing a college education, the security of a job would be mostly guaranteed. This is no longer the case and as a consequence, "In order to complete their education and begin work careers, young people now often linger in a state of 'semi-autonomy' during their 20s, combining support from their families with

The outcome of this *semiautonomy* is an inability to attain full autonomy through adulthood until much later on during one's late 20s, the peak of the adult crisis. Therefore, not only does a person need to become confident in the choices that define him or her as sources of meaning in their life through the resolution of their adult crisis, but they also need to have achieved adulthood. Not resolving this crisis can lead to feelings of disorientation and panic caused by a lack of confidence in personal identity. Ultimately, not knowing how to identify oneself in all aspects of life including your role as an adult will result in feelings of concern and depression.

This crisis in widely discussed in the media and is a household term, occurring during the early middle-age years, a variable age range. Wethington states that the midlife crisis is a term that "connotes personal turmoil and sudden changes in personal goals and lifestyle, brought about by the realization of aging, physical decline, or entrapment in unwelcome, restrictive roles" [3]. People often mistake this turmoil in life to be the result of high levels of stress. Indeed, though there is "expected stress" attributed with the midlife crisis, it is not the presence of stressors in life that causes the crisis. Indeed, there is a key difference between the midlife

As one article points out, "common psychosocial stressors may have severe and long-standing physiological and psychological consequences." The stressor is best described as an independent variable which is viewed as stressing to the individual. The summation of these stressors is sometimes defined as a midlife crisis but is

whatever they can make in the labor market and borrow."

version, level of attachment to others, etc.

*Cognitive Behavioral Therapy - Theories and Applications*

did in the past" [1].

**5.4 The midlife crisis**

crisis and a "midlife stressor."

**76**

People dealing with this crisis generally want to feel affirmed that they have led a meaningful life in which they have personally made a positive (or negative, depending on the sources of meaning) impact in the world. People who feel that they have led a meaningful life will typically and comfortably resolve this crisis and continue to lead a meaningful life. However, although having affirmed that they have led a meaningful life, some may not resolve this crisis and experience desperation as they try to make their lives even more meaningful before death. Such desperation can last until death and is usually experienced as an outlet of their fear of approaching death.

us through the anxiety we feel, to find the meaning. It would be appropriate to hypothesize that with more meaning and consequential satisfaction among the population, there would be less violence, more productivity, and more general

*Using Matching "Smarts" and Interest to Successfully Address Depression…*

periods of life crisis and the stages of model of hierarchical complexity. A huge component of failure in treatment is due to lack of accurate matching of the instruments to an individual. Matching helps figure out at what stage an individual is at

Cognitive behavioral treatment will be more effective if the focus is more on the

In future studies, we would like to match people to the causes of the crisis, for example, their career/job or their life partners, and resolve the crisis using the three

\*, Mansi Jitendra Shah<sup>2</sup> and Mark Hansen Keffer<sup>3</sup>

tolerance among people.

suites of matching instrument.

**Author details**

**79**

Michael Lamport Commons<sup>1</sup>

1 Harvard Medical School, MA, United States of America

3 Georgetown University, DC, United States of America

\*Address all correspondence to: commonsmlc@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

2 Dare Institute, MA, United States of America

provided the original work is properly cited.

and helps us plan out an intervention treatment.

*DOI: http://dx.doi.org/10.5772/intechopen.84337*

On the other hand, those who feel they have not found meaning in their lives will likely experience depression and hopelessness up until death. "Thirty percent of those who said they had suffered a crisis in their 60s said the long-term effect was totally negative." These negative effects are likely the embodiment of the depression and hopelessness which result from a lack of resolution within this crisis. People who experience these negative effects will believe themselves to have not led a meaningful life and, due to old age and little time left, will experience very little hope of correcting their life choices. The article states that in order to "avoid a latelife crisis in your 60s," a person should "maintain physical, financial and emotional health," "work longer," "use your time in a positive way," and "develop and maintain a strong support network."

Though it is true that doing each of these things will likely prevent an individual from experiencing a crisis in their 60s, it does not prevent the crisis from occurring entirely. They are better understood as avoidance methods which only dealt the crisis. Each of these actions elicits levels of reinforcement which will likely cloud one's existential thoughts through mere busyness. Therefore, though this reinforcement will delay an existential crisis, if a person has not led a meaningful life, their crisis will surely catch up with them.

Avoidance methods aside from one piece of advice that is helpful for potentially resolving the later-life crisis if a person has not found their life to be meaningful up to this point is found in Johns Hopkins Medicine: "Instead of lamenting what you never did, or what you've lost, Arbaje suggests thinking about this time as a chance to take on new challenges and embrace life in a new way" [22]. Indeed, this idea of embracing life in a new way raises the opportunity of making new life choices that align with the meaningfulness which one desires in life.

Through such embracement, the later-life crisis can potentially be resolved, though it is rare due to the difficulty caused by old age and a lack of energy. Indeed, "it is in accepting the reality of death, the fact that it will occur, that can give meaning and significance to living by emphasizing that our time is limited and therefore we must do what we value" [23].

However, such embracement of new potential sources of meaning is better deployed in pursuit of resolution of earlier crises such as the midlife crisis. Indeed, it is important to recognize that life is fleeting early on in one's life before it is too late to make the most of one's life and find meaning. The best method by which the later-life crisis can be resolved is through the resolution of one's earlier crises in life. Otherwise, there will certainly be negative effects from this crisis, elicited by an acknowledgment of a lack of meaning in one's life.

#### **6. Conclusion**

There are negative side effects to existential crises if they are not resolved, such as depression. If resolved, however, existential crises serve a great purpose in our lives, providing an opportunity to find meaning and purpose. The crises may push

*Using Matching "Smarts" and Interest to Successfully Address Depression… DOI: http://dx.doi.org/10.5772/intechopen.84337*

us through the anxiety we feel, to find the meaning. It would be appropriate to hypothesize that with more meaning and consequential satisfaction among the population, there would be less violence, more productivity, and more general tolerance among people.

Cognitive behavioral treatment will be more effective if the focus is more on the periods of life crisis and the stages of model of hierarchical complexity. A huge component of failure in treatment is due to lack of accurate matching of the instruments to an individual. Matching helps figure out at what stage an individual is at and helps us plan out an intervention treatment.

In future studies, we would like to match people to the causes of the crisis, for example, their career/job or their life partners, and resolve the crisis using the three suites of matching instrument.

#### **Author details**

People dealing with this crisis generally want to feel affirmed that they have led

On the other hand, those who feel they have not found meaning in their lives will likely experience depression and hopelessness up until death. "Thirty percent of those who said they had suffered a crisis in their 60s said the long-term effect was totally negative." These negative effects are likely the embodiment of the depression and hopelessness which result from a lack of resolution within this crisis. People who experience these negative effects will believe themselves to have not led a meaningful life and, due to old age and little time left, will experience very little hope of correcting their life choices. The article states that in order to "avoid a latelife crisis in your 60s," a person should "maintain physical, financial and emotional health," "work longer," "use your time in a positive way," and "develop and main-

Though it is true that doing each of these things will likely prevent an individual from experiencing a crisis in their 60s, it does not prevent the crisis from occurring entirely. They are better understood as avoidance methods which only dealt the crisis. Each of these actions elicits levels of reinforcement which will likely cloud one's existential thoughts through mere busyness. Therefore, though this reinforcement will delay an existential crisis, if a person has not led a meaningful life, their

Avoidance methods aside from one piece of advice that is helpful for potentially resolving the later-life crisis if a person has not found their life to be meaningful up to this point is found in Johns Hopkins Medicine: "Instead of lamenting what you never did, or what you've lost, Arbaje suggests thinking about this time as a chance to take on new challenges and embrace life in a new way" [22]. Indeed, this idea of embracing life in a new way raises the opportunity of making new life choices that

Through such embracement, the later-life crisis can potentially be resolved, though it is rare due to the difficulty caused by old age and a lack of energy. Indeed, "it is in accepting the reality of death, the fact that it will occur, that can give meaning and significance to living by emphasizing that our time is limited and

However, such embracement of new potential sources of meaning is better deployed in pursuit of resolution of earlier crises such as the midlife crisis. Indeed, it is important to recognize that life is fleeting early on in one's life before it is too late to make the most of one's life and find meaning. The best method by which the later-life crisis can be resolved is through the resolution of one's earlier crises in life. Otherwise, there will certainly be negative effects from this crisis, elicited by an

There are negative side effects to existential crises if they are not resolved, such as depression. If resolved, however, existential crises serve a great purpose in our lives, providing an opportunity to find meaning and purpose. The crises may push

a meaningful life in which they have personally made a positive (or negative, depending on the sources of meaning) impact in the world. People who feel that they have led a meaningful life will typically and comfortably resolve this crisis and continue to lead a meaningful life. However, although having affirmed that they have led a meaningful life, some may not resolve this crisis and experience desperation as they try to make their lives even more meaningful before death. Such desperation can last until death and is usually experienced as an outlet of their fear

*Cognitive Behavioral Therapy - Theories and Applications*

of approaching death.

tain a strong support network."

crisis will surely catch up with them.

align with the meaningfulness which one desires in life.

therefore we must do what we value" [23].

acknowledgment of a lack of meaning in one's life.

**6. Conclusion**

**78**

Michael Lamport Commons<sup>1</sup> \*, Mansi Jitendra Shah<sup>2</sup> and Mark Hansen Keffer<sup>3</sup>


\*Address all correspondence to: commonsmlc@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Erikson EH. Identity and the Life Cycle. W. W. Norton & Company (Reissue ed.); New York: International Universities Press, Inc.; 1994

[2] Perry WG. Forms of Ethical and Intellectual Development in the College Years: A Scheme. 1st ed. Bureau of Study Counsel, Harvard University: Wiley; 1998

[3] Andrews M. The existential crisis. Behavioral Developmental Bulletin. 2016;**21**(1):104-109. DOI: 10.1037/ bdb0000014

[4] Wethington E. Expecting stress: Americans and the midlife crisis. Motivation and Emotion. 2000;**24**: 85-102

[5] Krantz DH, Luce RD, Suppes P, Tversky A. Foundations of measurement. In: Additive and Polynomial Representations. Vol. I. New York, NY: Academic Press; 1971

[6] Luce RD, Tukey JW. Simultaneous conjoint measurement: A new scale type of fundamental measurement. Journal of Mathematical Psychology. 1964;**1**: 1-27

[7] Commons ML, Gane-McCalla R, Barker CD, Li EY. The model of hierarchical complexity as a measurement system. Behavioral Developmental Bulletin. 2014;**19**(3): 9-14

[8] Commons ML, Jiang TR. Introducing a new stage for the model of hierarchical complexity: A new stage for reflex conditioning. Behavioral Development Bulletin. 2014;**19**:1-8. DOI: 10.1037/ h0100582

[9] Pascual-Leone J. Piaget as a pioneer of dialectical constructivism: Seeking dynamic processes for human science.

In: Marti E, Rodriguez C, editors. After Piaget. Edison, NJ: Transaction Publishers; 2011. pp. 15-41

[18] Anderson C. PowerNomics, The National Plan to Empower Black America. 1st ed. Powernomics Corp of Amer; R R Bowker LLC publishing: The University of Michigan, USA; 2001

*DOI: http://dx.doi.org/10.5772/intechopen.84337*

*Using Matching "Smarts" and Interest to Successfully Address Depression…*

[19] Fitzgerald B. An existential view of adolescent development. Roslyn Heights. 2005;**40**(160):793-799

[20] Spear L. The adolescent brain and age-related behavioral manifestations. Neuroscience and Biobehavioral Reviews. 2000;**24**(4):417-463. DOI: 10.1016/s0149-7634(00)00014-2

[21] Emling S. 7 Signs You Might Be Facing A Midlife Crisis. 2013. Available from: http://www.huffingtonpost.com/ 2013/12/12/midlife-crisis\_n\_4419481. html [Retrieved 25 June 2017]

[22] Arbaje A. Healthy Mind: How to Cope with a Later-Life Crisis. n.d. Available from: http://www.

hopkinsmedicine.org/health/healthy\_ aging/healthy\_mind/how-to-cope-with-alater-life-crisis [Retrieved 27 July 2017]

[23] Tillich. 1952. http://www.ehow. com/list\_7484019\_jobs-duringrenaissance-period.html

**81**

[10] Pascual-Leone J, Johnson J. Organismic causal models "from within" clarify developmental change and stages. In: Budwig N, Turiel E, Zelazo P, editors. New perspectives on human development. Cambridge, United Kingdom: Cambridge University Press; 2017. DOI: 10.1017/ CBO9781316282755.006

[11] Inhelder B, Piaget J. The Growth of Logical Thinking from Childhood to Adolescence. New York, NY: Basic Books, Inc.; 1958

[12] Giri S. Cross-cultural homogeneity in social perspective taking: China and the United States. Behavioral Development Bulletin. 2016;**21**:176-183. DOI: 10.1037/bdb0000023

[13] Holland JL. Making Vocational Choices: A Theory of Vocational Personalities and Work Environments. 2nd ed. Englewood Cliffs, NJ: Prentice Hall; 1985

[14] Ramakrishnan S, Mei M, Giri S, Commons ML. Predicting success in academia using behavioral stage & Holland interest scores. In: Presented at the Society for Research in Adult Development; Salem, MA. 2016

[15] Van Deurzen E. Everyday Mysteries—Existential Dimensions of Psychotherapy. London, England: Routledge; 1997

[16] Schwartz B. The Paradox of Choice: Why More is Less. HarperCollins e-books; USA: Ecco Press; 2009

[17] Bigelow GE. A Primer of Existentialism. College English. 1961; **23**(3):171-178. DOI: 10.2307/373002

*Using Matching "Smarts" and Interest to Successfully Address Depression… DOI: http://dx.doi.org/10.5772/intechopen.84337*

[18] Anderson C. PowerNomics, The National Plan to Empower Black America. 1st ed. Powernomics Corp of Amer; R R Bowker LLC publishing: The University of Michigan, USA; 2001

**References**

Wiley; 1998

bdb0000014

85-102

1-27

9-14

h0100582

**80**

[1] Erikson EH. Identity and the Life Cycle. W. W. Norton & Company (Reissue ed.); New York: International

*Cognitive Behavioral Therapy - Theories and Applications*

In: Marti E, Rodriguez C, editors. After

[11] Inhelder B, Piaget J. The Growth of Logical Thinking from Childhood to Adolescence. New York, NY: Basic

[12] Giri S. Cross-cultural homogeneity in social perspective taking: China and

Development Bulletin. 2016;**21**:176-183.

[13] Holland JL. Making Vocational Choices: A Theory of Vocational Personalities and Work Environments. 2nd ed. Englewood Cliffs, NJ: Prentice

[14] Ramakrishnan S, Mei M, Giri S, Commons ML. Predicting success in academia using behavioral stage & Holland interest scores. In: Presented at the Society for Research in Adult Development; Salem, MA. 2016

[15] Van Deurzen E. Everyday

[17] Bigelow GE. A Primer of

Routledge; 1997

Mysteries—Existential Dimensions of Psychotherapy. London, England:

[16] Schwartz B. The Paradox of Choice: Why More is Less. HarperCollins e-books; USA: Ecco Press; 2009

Existentialism. College English. 1961; **23**(3):171-178. DOI: 10.2307/373002

the United States. Behavioral

DOI: 10.1037/bdb0000023

Piaget. Edison, NJ: Transaction Publishers; 2011. pp. 15-41

[10] Pascual-Leone J, Johnson J. Organismic causal models "from within" clarify developmental change and stages. In: Budwig N, Turiel E, Zelazo P, editors. New perspectives on human development. Cambridge, United Kingdom: Cambridge University

Press; 2017. DOI: 10.1017/ CBO9781316282755.006

Books, Inc.; 1958

Hall; 1985

[2] Perry WG. Forms of Ethical and Intellectual Development in the College Years: A Scheme. 1st ed. Bureau of Study Counsel, Harvard University:

[3] Andrews M. The existential crisis. Behavioral Developmental Bulletin. 2016;**21**(1):104-109. DOI: 10.1037/

[4] Wethington E. Expecting stress: Americans and the midlife crisis. Motivation and Emotion. 2000;**24**:

[5] Krantz DH, Luce RD, Suppes P,

York, NY: Academic Press; 1971

Polynomial Representations. Vol. I. New

[6] Luce RD, Tukey JW. Simultaneous conjoint measurement: A new scale type of fundamental measurement. Journal of Mathematical Psychology. 1964;**1**:

[7] Commons ML, Gane-McCalla R, Barker CD, Li EY. The model of hierarchical complexity as a measurement system. Behavioral Developmental Bulletin. 2014;**19**(3):

[8] Commons ML, Jiang TR. Introducing a new stage for the model of hierarchical complexity: A new stage for reflex conditioning. Behavioral Development Bulletin. 2014;**19**:1-8. DOI: 10.1037/

[9] Pascual-Leone J. Piaget as a pioneer of dialectical constructivism: Seeking dynamic processes for human science.

Tversky A. Foundations of measurement. In: Additive and

Universities Press, Inc.; 1994

[19] Fitzgerald B. An existential view of adolescent development. Roslyn Heights. 2005;**40**(160):793-799

[20] Spear L. The adolescent brain and age-related behavioral manifestations. Neuroscience and Biobehavioral Reviews. 2000;**24**(4):417-463. DOI: 10.1016/s0149-7634(00)00014-2

[21] Emling S. 7 Signs You Might Be Facing A Midlife Crisis. 2013. Available from: http://www.huffingtonpost.com/ 2013/12/12/midlife-crisis\_n\_4419481. html [Retrieved 25 June 2017]

[22] Arbaje A. Healthy Mind: How to Cope with a Later-Life Crisis. n.d. Available from: http://www. hopkinsmedicine.org/health/healthy\_ aging/healthy\_mind/how-to-cope-with-alater-life-crisis [Retrieved 27 July 2017]

[23] Tillich. 1952. http://www.ehow. com/list\_7484019\_jobs-duringrenaissance-period.html

**83**

**Chapter 6**

**Abstract**

**1. Introduction**

of human behavior [2].

idea of brain plasticity in adolescence [5].

Health Contexts

Neurosciences and Emotional

Self-Regulation Applied to Mental

*Prisla Ücker Calvetti, Fernanda de Vargas and Gabriel Gauer*

Mapping the self-regulation in the therapeutic process may be important to characterize the picture better, to contribute to the planning of the therapy and to select strategies for practical guidance of the patient, which will favor positive gains. It is important to know more and more the cognitive responses and behavioral characteristics of patients, such as associative learning, motivation and regulation of emotion, which may be linked to the genesis and maintenance of disease. We highlight self-regulation that is an executive function managed by the prefrontal cortex of the frontal lobe of the brain, essential to keep the individual active in the process to achieve their goals. It is a complex phenomenon that involves behavior (activation, monitoring, inhibition, preservation and adaptation), emotions and cognitive strategies to achieve desired goals. The neurosciences can contribute to the knowledge in emotional self-regulation in children and adolescents to health contexts in CBT.

During the process of structuring the personality, there are many social and individual factors that can motivate or inhibit aggressive conduct. So it is necessary to consider there is a complex relationship between social risk factors psychological and biological, that is, the behavior is multidetermined by a set of variables [1]. In addition studies in the aforementioned areas are gaining space also in the field of law, since discoveries about brain development can contribute to the understanding

The advancement of neurosciences enabled the understanding that during adolescence there is an incomplete development of some brain regions [3], among these would be those responsible for behavioral control and impulsiveness [4]. In addition empirical research shows that experiences can produce alterations in the neural structure of the subjects, thus, it is reasonable to affirm that the cerebral cortex can be continuously remodeled from new experiences, from which comes the

Therefore, studies in the field of neuroscience corroborate to understand the development of children and adolescents as regards the individual characteristics of adolescents in socio-educational measures. These findings may contribute to

**Keywords:** neurosciences, emotional self-regulation, health

#### **Chapter 6**

## Neurosciences and Emotional Self-Regulation Applied to Mental Health Contexts

*Prisla Ücker Calvetti, Fernanda de Vargas and Gabriel Gauer*

#### **Abstract**

Mapping the self-regulation in the therapeutic process may be important to characterize the picture better, to contribute to the planning of the therapy and to select strategies for practical guidance of the patient, which will favor positive gains. It is important to know more and more the cognitive responses and behavioral characteristics of patients, such as associative learning, motivation and regulation of emotion, which may be linked to the genesis and maintenance of disease. We highlight self-regulation that is an executive function managed by the prefrontal cortex of the frontal lobe of the brain, essential to keep the individual active in the process to achieve their goals. It is a complex phenomenon that involves behavior (activation, monitoring, inhibition, preservation and adaptation), emotions and cognitive strategies to achieve desired goals. The neurosciences can contribute to the knowledge in emotional self-regulation in children and adolescents to health contexts in CBT.

**Keywords:** neurosciences, emotional self-regulation, health

#### **1. Introduction**

During the process of structuring the personality, there are many social and individual factors that can motivate or inhibit aggressive conduct. So it is necessary to consider there is a complex relationship between social risk factors psychological and biological, that is, the behavior is multidetermined by a set of variables [1]. In addition studies in the aforementioned areas are gaining space also in the field of law, since discoveries about brain development can contribute to the understanding of human behavior [2].

The advancement of neurosciences enabled the understanding that during adolescence there is an incomplete development of some brain regions [3], among these would be those responsible for behavioral control and impulsiveness [4]. In addition empirical research shows that experiences can produce alterations in the neural structure of the subjects, thus, it is reasonable to affirm that the cerebral cortex can be continuously remodeled from new experiences, from which comes the idea of brain plasticity in adolescence [5].

Therefore, studies in the field of neuroscience corroborate to understand the development of children and adolescents as regards the individual characteristics of adolescents in socio-educational measures. These findings may contribute to

the proposed care programs in the implementation of the hospitalization measure can be more effective and coherent with the individualization of measures and the pedagogical character of the same. Appropriate interventions can enable the development of new cerebral connections and the change of perception about the crime, the fulfillment of the measure, the relationships established outside the institution among other aspects. In this way, it would be feasible to think that the integration of different variables, social and individual, could make socio-educational measures more effective. This chapter has the objective of shows the contributions neuroscience and emotional self-regulation in mental health contexts to cognitive behavioral therapy (CBT). For this, it is important to considerer the human development in the period from adolescence to adult life.

#### **2. Adolescence: peculiar period of development**

Puberty is a phenomenon that has always existed in the history of mankind, however the concept of adolescence,1 as it is currently defined, began to be discussed only from the eighteenth century onwards. In this way, adolescence is correlated with many changes that have occurred at the cultural, social, economic and historical level in several civilizations [6].

In the eighteenth century, with the Enlightenment, a new movement of the society at that time, there is a redefinition of the social roles of women and children, as well as there is a new focus on family issues. The child is seen as the future of the family and the object of love of the parents, and with that there is a greater investment in the relationship between parents and children. At this moment the child is not seem merely as a miniature adult, but as a person, a subject of wills, rights [7] and peculiar characteristics. Still in the nineteenth century, adolescence becomes perceived as a critical moment of human development, which poses potential risks to the subject and also to society, and therefore becomes thematic studied among physicians and educators [8].

From this, it arises the need to specify the transformations arising in adolescence, physical and also behavioral modifications. The adolescence is defined by the psychological and social maturation process that accompanies or begins with puberty. On the other hand, it can be considered a biological phenomenon that produces physiological and morphological changes [9]. Thus, adolescence is characterized as the phase of the life cycle in which the personality is structured, and that there is emotional instability in the face of physical modifications that occur in body and the search for identity formation [10].

In addition to changes in the body, at 11, or 12 years old, some cognitive structures of the child also mature. The kid will develop the reasoning and logic needed to troubleshoot solutions. Piaget [11] called this period "formal operations". Among the biological changes of this period it can be emphasized the changes in the activities of different regions of the brain, which are part of the process of cerebral maturation [12]—childhood and adolescence seem to be essential phases in this process. Research shows that childhood experiences will exert significant influence on the development of behaviors in adulthood and that, environmental stimuli influence the development of different neural circuits in that period [13].

**85**

*Neurosciences and Emotional Self-Regulation Applied to Mental Health Contexts*

It is thought that in adolescence there is neurocognitive immaturity, because there are some brain areas that are still in development. The situations lived during this period are also significant for the myelination of areas of the brain, mainly of prefrontal areas, responsible for rationalization, taking impulse control. In addition, recent findings show that this myelination may extend to the third decade of life. Previous longitudinal studies have already evidenced that the maturation process that depends

on myelin could go up to the 21-year-old, according to the population studied.

the brain and the cognitive processes has increased in recent years [16].

Among the most researched cognitive processes currently, are the executive functions (EF) [17], complex mental functions responsible for the ability of the subject to engage in attitudes aimed at goals, that is, how this subject organizes and plans their actions in search of specific goals. Other skills related to executive functions are to create strategies, solve problems, monitor behavior, make decisions,

Moreover, the EF will allow the management of emotions and impulses, seeking a more appropriate response to the situations, what we can call autoregulation [18]. Considering that impulsivity can be classified as a poorly adapted response, without prior planning and associated with the desire for immediate satisfaction [19], the ability to resolve conflicting information and inhibit automatic replies when necessary, is understood as an indicator of the ability to direct future-oriented behavior [20]. Subjects who have decreased impulse control capacity can commit harmful acts to themselves and others [21]. Moreover, impulsiveness appears as a symptom of different psychiatric disorders, such as conduct disorder, personality disorder antisocial, personality disorder borderline, attention deficit and hyperactivity

In view of this, the number of researches that have been focused on the neuropsychological assessment of impulsiveness and inhibitory control is increasing. Like this, the continuous performance tests (Go/No Go Task) have been presented as a promising task to evaluate mechanisms involved in the impulsive behaviors and self-regulation of the emission of motor responses [23]. This task is development in display (on computer) stimuli target (words, images, videos, and others) for the participants. These are instructed to press a computer key as quickly as possible (for the stimuli *act*) and do not perform any response in the presence of stimuli *don't act*, according to each task. From this, it is possible to observe three important aspects to evaluate the behavior: the omission in executing a response expected the realization of an undue response and the time each participant took to make the answers. The

In addition to an incomplete development in areas related to impulse control, there is also a higher intensity of impulsiveness in adolescents. With the use of functional magnetic resonance imaging, researchers observed that in a given task performed by the sample studied, referring to the gratification, the nucleus *accumbens*, a brain structure related to the reward system, showed a more pronounced activation than in adults who performed the same task. Thus, studies of this type corroborate the existence of exacerbated impulsiveness in adolescence [14].

It is during adolescence also, that the process of consolidation of different devices related to social cognition occurs, such as: the ability to interact with others based on the perception and recognition of emotions expressed by the face; the understanding of other people's mental states; and the regulation of behaviors in the face of an interpersonal situation [15]. These functions are of utmost importance in the face of understanding behavior. They are the ones that make it possible for subjects to interact, meet, perceive and relate to the world and the people around them. It is noteworthy that the interest in understanding the relationship established between

**2.1 Adolescence and development: neuropsychological aspects**

*DOI: http://dx.doi.org/10.5772/intechopen.83791*

abstract, reason, among others.

(ADHD), psychopathy, among others [22].

<sup>1</sup> The World Health Organization (WHO) separates adolescence in two phases, the first of 10–16 years of age and the second, from 16 to 20 years. Legislation Brasilian, according to the Statute Child and Adolescent Considers adolescent people between the ages of 12 and 18 years old.

#### **2.1 Adolescence and development: neuropsychological aspects**

It is thought that in adolescence there is neurocognitive immaturity, because there are some brain areas that are still in development. The situations lived during this period are also significant for the myelination of areas of the brain, mainly of prefrontal areas, responsible for rationalization, taking impulse control. In addition, recent findings show that this myelination may extend to the third decade of life. Previous longitudinal studies have already evidenced that the maturation process that depends on myelin could go up to the 21-year-old, according to the population studied.

In addition to an incomplete development in areas related to impulse control, there is also a higher intensity of impulsiveness in adolescents. With the use of functional magnetic resonance imaging, researchers observed that in a given task performed by the sample studied, referring to the gratification, the nucleus *accumbens*, a brain structure related to the reward system, showed a more pronounced activation than in adults who performed the same task. Thus, studies of this type corroborate the existence of exacerbated impulsiveness in adolescence [14].

It is during adolescence also, that the process of consolidation of different devices related to social cognition occurs, such as: the ability to interact with others based on the perception and recognition of emotions expressed by the face; the understanding of other people's mental states; and the regulation of behaviors in the face of an interpersonal situation [15]. These functions are of utmost importance in the face of understanding behavior. They are the ones that make it possible for subjects to interact, meet, perceive and relate to the world and the people around them. It is noteworthy that the interest in understanding the relationship established between the brain and the cognitive processes has increased in recent years [16].

Among the most researched cognitive processes currently, are the executive functions (EF) [17], complex mental functions responsible for the ability of the subject to engage in attitudes aimed at goals, that is, how this subject organizes and plans their actions in search of specific goals. Other skills related to executive functions are to create strategies, solve problems, monitor behavior, make decisions, abstract, reason, among others.

Moreover, the EF will allow the management of emotions and impulses, seeking a more appropriate response to the situations, what we can call autoregulation [18]. Considering that impulsivity can be classified as a poorly adapted response, without prior planning and associated with the desire for immediate satisfaction [19], the ability to resolve conflicting information and inhibit automatic replies when necessary, is understood as an indicator of the ability to direct future-oriented behavior [20]. Subjects who have decreased impulse control capacity can commit harmful acts to themselves and others [21]. Moreover, impulsiveness appears as a symptom of different psychiatric disorders, such as conduct disorder, personality disorder antisocial, personality disorder borderline, attention deficit and hyperactivity (ADHD), psychopathy, among others [22].

In view of this, the number of researches that have been focused on the neuropsychological assessment of impulsiveness and inhibitory control is increasing. Like this, the continuous performance tests (Go/No Go Task) have been presented as a promising task to evaluate mechanisms involved in the impulsive behaviors and self-regulation of the emission of motor responses [23]. This task is development in display (on computer) stimuli target (words, images, videos, and others) for the participants. These are instructed to press a computer key as quickly as possible (for the stimuli *act*) and do not perform any response in the presence of stimuli *don't act*, according to each task. From this, it is possible to observe three important aspects to evaluate the behavior: the omission in executing a response expected the realization of an undue response and the time each participant took to make the answers. The

*Cognitive Behavioral Therapy - Theories and Applications*

period from adolescence to adult life.

however the concept of adolescence,1

physicians and educators [8].

and the search for identity formation [10].

and historical level in several civilizations [6].

**2. Adolescence: peculiar period of development**

the proposed care programs in the implementation of the hospitalization measure can be more effective and coherent with the individualization of measures and the pedagogical character of the same. Appropriate interventions can enable the development of new cerebral connections and the change of perception about the crime, the fulfillment of the measure, the relationships established outside the institution among other aspects. In this way, it would be feasible to think that the integration of different variables, social and individual, could make socio-educational measures more effective. This chapter has the objective of shows the contributions neuroscience and emotional self-regulation in mental health contexts to cognitive behavioral therapy (CBT). For this, it is important to considerer the human development in the

Puberty is a phenomenon that has always existed in the history of mankind,

In the eighteenth century, with the Enlightenment, a new movement of the society at that time, there is a redefinition of the social roles of women and children, as well as there is a new focus on family issues. The child is seen as the future of the family and the object of love of the parents, and with that there is a greater investment in the relationship between parents and children. At this moment the child is not seem merely as a miniature adult, but as a person, a subject of wills, rights [7] and peculiar characteristics. Still in the nineteenth century, adolescence becomes perceived as a critical moment of human development, which poses potential risks to the subject and also to society, and therefore becomes thematic studied among

From this, it arises the need to specify the transformations arising in adolescence, physical and also behavioral modifications. The adolescence is defined by the psychological and social maturation process that accompanies or begins with puberty. On the other hand, it can be considered a biological phenomenon that produces physiological and morphological changes [9]. Thus, adolescence is characterized as the phase of the life cycle in which the personality is structured, and that there is emotional instability in the face of physical modifications that occur in body

In addition to changes in the body, at 11, or 12 years old, some cognitive structures of the child also mature. The kid will develop the reasoning and logic needed to troubleshoot solutions. Piaget [11] called this period "formal operations". Among the biological changes of this period it can be emphasized the changes in the activities of different regions of the brain, which are part of the process of cerebral maturation [12]—childhood and adolescence seem to be essential phases in this process. Research shows that childhood experiences will exert significant influence on the development of behaviors in adulthood and that, environmental stimuli influence the development of different neural circuits

<sup>1</sup> The World Health Organization (WHO) separates adolescence in two phases, the first of 10–16 years of age and the second, from 16 to 20 years. Legislation Brasilian, according to the Statute Child and

Adolescent Considers adolescent people between the ages of 12 and 18 years old.

cussed only from the eighteenth century onwards. In this way, adolescence is correlated with many changes that have occurred at the cultural, social, economic

as it is currently defined, began to be dis-

**84**

in that period [13].

frequency of omission errors is often related to inattention in the execution of the task, while the frequency of commission errors is associated with impulsiveness and failure to inhibit a prepotent response. The reaction time for the responses, allows to identify the speed of the processing of the information [24].

So, it aims to evaluate the performance of children and adolescents in relation to the inhibitory component of executive functions, from Go/No Go tasks have been performed in different contexts. The study of Bilous, Small and Salles [25] with children presented as a result, to higher performance in the Go/No Go task in children in early school grades, being in agreement with other studies [26, 27]. That indicates the maturation of the cortical regions associated with executive functions with increasing age and with this, possibly the improvement in the performance of these tasks. With teenagers, this result is similar, [28] found differences statistically significant in the Go/No Go task performance according to the age range, demonstrating a chronological increase in the inhibitory control, in addition to finding differences in the performance between the participants gender (lower inhibitory control in females) and in private and public school students (better performance in private school students).

These results converge to the understanding that executive functions are related to different aspects of development and need to be evaluated taking into account different variables. Therefore, research in this field suggests that early interventions geared towards self-regulation are effective in promotion of executive functions skills [29, 30]. Activities such as, Yoga, mental training, aerobic exercises, among others, can provide ample benefits for the control of impulses, working memory and change of focus of attention, these skills, involved in the EF [31].

The Go/No go task has also been used to investigate the brain areas involved (activated) during the process of inhibiting responses, based on the use of neuroimaging techniques. An example of this is the study by Goya-Maldonado and collaborators [32] which found a positive correlation between the activation of areas of the ventrolateral prefrontal cortex and motor impulsiveness, during successful responses of inhibition a Go/No Go task. This study corroborates the interpretation that the prefrontal cortex is involved in the processes of planning, self-regulation of behavior and inhibitory responses.

The neurological bases of the EF are located in the prefrontal cortex, more specifically the region lateral and anterior cingulate gyrus [33]. It is noteworthy that the prefrontal cortex is not only involved in cognitive processes, because a region orbital frontal is related emotional aspects of the inhibitory control, so prefrontal lesions can also cause cognitive and emotional disturbances [34]. That is because the orbitofrontal cortex maintains connections with the limbic system, unit responsible for the emotions and by social behaviors. In addition, the frontal lobe comprises limbic structures, since the anterior portion of the cingulate plays an essential role in primary emotions, along with the amygdala [35].

In this way it is observed that the executive functions need the activity of several neural circuits, being correct to affirm that the whole brain participates in this process. However, the prefrontal cortex region is the last to develop, that is, to reach the maturational [36], therefore the EF takes longer to mature, and in adolescents this process is still under development. It is emphasized that the maturation of the executive functions occurs continuously, but there are outbreaks of development in certain ages of the individual, such as at 2, 6 and 8 years of age, lasting significantly until the end of adolescence and early adulthood [37].

When executive function changes occur, the syndrome, which is related to several cognitive and psychiatric disorders, may be related to neurological injuries or dysfunctions. In view of this context, there was an increase in research on executive functions, and about psychiatric and cognitive disorders related to dysfunctions

**87**

neutral faces [50].

*Neurosciences and Emotional Self-Regulation Applied to Mental Health Contexts*

of the same. However, as regards studies with children and adolescents in Brazil, most of the studies are about attention deficit hyperactivity disorder (ADHD) [38], autism, learning disabilities [39], and use of psychoactive substances [40], few national studies discuss the theme of executive function related to violence and the

However, international studies [41] evidence of low performance of executive functions, in neuropsychological measures, in individuals with psychiatric disorders that are associated with aggression, such as antisocial personality disorder, conduct disorder, bipolar disorder among others. In addition, several researches [42, 43] feature a significant relationship between cerebral dysfunctions and violent behavior, both in adults and adolescents, evidencing biological aspects as risk fac-

In view of the above, it is observed that failures in the inhibition of antisocial behaviors are related to a less responsive brain circuit that does not fulfill its function of managing the behavior in a full way, based on social values established [44]. This occurs in both adults and adolescents, however, the phase of adolescence is peculiar, in the sense that the cortex prefrontal is the last structure to develop, which would explain some characteristics of this phase, such as, impulsiveness, difficulty in planning, limitation in braking the search for immediate pleasure and

In this sense, many studies have turned to the understanding of psychopathy and its development. Although criminal behavior is not an essential diagnostic criterion in this disorder, some central characteristics of psychopathy favor the involvement in anti-social behaviors [45]. Thus, even if psychopathy is a diagnosis that can only be performed after 18 years of age, many studies are performed with adolescents, seeking to identify possible neurocognitive dysfunctions and traces of the disorder that present some level of relationship with the picture in adulthood. One of the neurocognitive dysfunctions that has been investigated in children and adolescents, it concerns deficits in the processing of information about different types of emotional content, since such characteristics do not develop suddenly in adulthood, these deficits, traits and tendencies that can culminating in a psycho-

In this way, the besides studies conducted with adults, researches with children and adolescents have also been conducted in order to investigate deficits in the processing of certain emotions and have found of the convergent results with regard to the existence of these deficits in relation to the expression of fear, in children and adolescents with a tendency to psychopathy when compared to control groups [47–49]. Researchers have also found a relationship between the different facets of the psychopathy framework (affective facet and antisocial facet) and deficits in recognition of expressions, for example, the affective facet, related to emotional insensitivity was more associated with the deficits of fear recognition, while the antisocial facet was more associated with the attribution of rabies in

In adults, the results of studies show similar to those found in younger populations. Compared the performance in identifying negative emotions (anger, sadness and fear) expressed by the face, in criminal and non-criminal individuals with different levels of psychopathy, using the Go/No Go task. Individuals with "more severe" psychopathy presented worse performance than groups with "low psychopathy" in recognizing expressions of fear and sadness. These results reinforce the idea that psychopathy is related to the low ability to identify fear and sadness in facial expressions. Different studies have been converging on the diminished capacity of psychopaths in identifying certain facial expressions. Most of the findings suggest that there seems to be a deficiency in the processing emotional psychopaths [50].

the fragile concern with the consequences of their actions.

pathic disorder can be observed already at early ages [46].

*DOI: http://dx.doi.org/10.5772/intechopen.83791*

committing of crimes in adolescents.

tors for this type of behavior.

#### *Neurosciences and Emotional Self-Regulation Applied to Mental Health Contexts DOI: http://dx.doi.org/10.5772/intechopen.83791*

of the same. However, as regards studies with children and adolescents in Brazil, most of the studies are about attention deficit hyperactivity disorder (ADHD) [38], autism, learning disabilities [39], and use of psychoactive substances [40], few national studies discuss the theme of executive function related to violence and the committing of crimes in adolescents.

However, international studies [41] evidence of low performance of executive functions, in neuropsychological measures, in individuals with psychiatric disorders that are associated with aggression, such as antisocial personality disorder, conduct disorder, bipolar disorder among others. In addition, several researches [42, 43] feature a significant relationship between cerebral dysfunctions and violent behavior, both in adults and adolescents, evidencing biological aspects as risk factors for this type of behavior.

In view of the above, it is observed that failures in the inhibition of antisocial behaviors are related to a less responsive brain circuit that does not fulfill its function of managing the behavior in a full way, based on social values established [44]. This occurs in both adults and adolescents, however, the phase of adolescence is peculiar, in the sense that the cortex prefrontal is the last structure to develop, which would explain some characteristics of this phase, such as, impulsiveness, difficulty in planning, limitation in braking the search for immediate pleasure and the fragile concern with the consequences of their actions.

In this sense, many studies have turned to the understanding of psychopathy and its development. Although criminal behavior is not an essential diagnostic criterion in this disorder, some central characteristics of psychopathy favor the involvement in anti-social behaviors [45]. Thus, even if psychopathy is a diagnosis that can only be performed after 18 years of age, many studies are performed with adolescents, seeking to identify possible neurocognitive dysfunctions and traces of the disorder that present some level of relationship with the picture in adulthood. One of the neurocognitive dysfunctions that has been investigated in children and adolescents, it concerns deficits in the processing of information about different types of emotional content, since such characteristics do not develop suddenly in adulthood, these deficits, traits and tendencies that can culminating in a psychopathic disorder can be observed already at early ages [46].

In this way, the besides studies conducted with adults, researches with children and adolescents have also been conducted in order to investigate deficits in the processing of certain emotions and have found of the convergent results with regard to the existence of these deficits in relation to the expression of fear, in children and adolescents with a tendency to psychopathy when compared to control groups [47–49]. Researchers have also found a relationship between the different facets of the psychopathy framework (affective facet and antisocial facet) and deficits in recognition of expressions, for example, the affective facet, related to emotional insensitivity was more associated with the deficits of fear recognition, while the antisocial facet was more associated with the attribution of rabies in neutral faces [50].

In adults, the results of studies show similar to those found in younger populations. Compared the performance in identifying negative emotions (anger, sadness and fear) expressed by the face, in criminal and non-criminal individuals with different levels of psychopathy, using the Go/No Go task. Individuals with "more severe" psychopathy presented worse performance than groups with "low psychopathy" in recognizing expressions of fear and sadness. These results reinforce the idea that psychopathy is related to the low ability to identify fear and sadness in facial expressions. Different studies have been converging on the diminished capacity of psychopaths in identifying certain facial expressions. Most of the findings suggest that there seems to be a deficiency in the processing emotional psychopaths [50].

*Cognitive Behavioral Therapy - Theories and Applications*

private school students).

behavior and inhibitory responses.

role in primary emotions, along with the amygdala [35].

until the end of adolescence and early adulthood [37].

identify the speed of the processing of the information [24].

frequency of omission errors is often related to inattention in the execution of the task, while the frequency of commission errors is associated with impulsiveness and failure to inhibit a prepotent response. The reaction time for the responses, allows to

So, it aims to evaluate the performance of children and adolescents in relation to the inhibitory component of executive functions, from Go/No Go tasks have been performed in different contexts. The study of Bilous, Small and Salles [25] with children presented as a result, to higher performance in the Go/No Go task in children in early school grades, being in agreement with other studies [26, 27]. That indicates the maturation of the cortical regions associated with executive functions with increasing age and with this, possibly the improvement in the performance of these tasks. With teenagers, this result is similar, [28] found differences statistically significant in the Go/No Go task performance according to the age range, demonstrating a chronological increase in the inhibitory control, in addition to finding differences in the performance between the participants gender (lower inhibitory control in females) and in private and public school students (better performance in

These results converge to the understanding that executive functions are related to different aspects of development and need to be evaluated taking into account different variables. Therefore, research in this field suggests that early interventions geared towards self-regulation are effective in promotion of executive functions skills [29, 30]. Activities such as, Yoga, mental training, aerobic exercises, among others, can provide ample benefits for the control of impulses, working memory

The Go/No go task has also been used to investigate the brain areas involved (activated) during the process of inhibiting responses, based on the use of neuroimaging techniques. An example of this is the study by Goya-Maldonado and collaborators [32] which found a positive correlation between the activation of areas of the ventrolateral prefrontal cortex and motor impulsiveness, during successful responses of inhibition a Go/No Go task. This study corroborates the interpretation that the prefrontal cortex is involved in the processes of planning, self-regulation of

The neurological bases of the EF are located in the prefrontal cortex, more specifically the region lateral and anterior cingulate gyrus [33]. It is noteworthy that the prefrontal cortex is not only involved in cognitive processes, because a region orbital frontal is related emotional aspects of the inhibitory control, so prefrontal lesions can also cause cognitive and emotional disturbances [34]. That is because the orbitofrontal cortex maintains connections with the limbic system, unit responsible for the emotions and by social behaviors. In addition, the frontal lobe comprises limbic structures, since the anterior portion of the cingulate plays an essential

In this way it is observed that the executive functions need the activity of several

When executive function changes occur, the syndrome, which is related to several cognitive and psychiatric disorders, may be related to neurological injuries or dysfunctions. In view of this context, there was an increase in research on executive functions, and about psychiatric and cognitive disorders related to dysfunctions

neural circuits, being correct to affirm that the whole brain participates in this process. However, the prefrontal cortex region is the last to develop, that is, to reach the maturational [36], therefore the EF takes longer to mature, and in adolescents this process is still under development. It is emphasized that the maturation of the executive functions occurs continuously, but there are outbreaks of development in certain ages of the individual, such as at 2, 6 and 8 years of age, lasting significantly

and change of focus of attention, these skills, involved in the EF [31].

**86**

Studies with neuroimaging also find similar results, since the limbic system, more specifically, the amygdala, are involved in this capacity [51].

These results may explain the "coolness" found in the psychopathic conditions, because a lesser capacity to respond adequately to other people's emotions seems be at the root of different behaviors antisocial. Therefore, researches in this field can generate greater understanding about these deficiencies and contribute to the development of interventions of emotional recognition training, among others, in an early way, with the objective of generating greater effectiveness in treatment of adolescents with antisocial behaviors.

Finally, most studies and theories that sought to understand violence, involved almost in its entirety, social models and sociological, it is noteworthy that neuropsychology is also an area that can contribute in the knowledge criminal behavior. The attention on the anatomical base what involve these behaviors is important for the treatment of violence and the crimes present in our society [52].

In this sense, it is not about denying the importance of the environment in the formation of the subjects, but of recognizing that the social factors are relevant in the development the violent behavior can occur from an interaction with biological aspects. In addition, the experiences experienced in the environment contribute to biological changes that are related to the predisposition to violence.

Among these biological aspects one can think of genetic factors; hormonal factors; brain factors, both with regard to the structure and the functionality of the cerebrum; among other aspects. From this understanding, the subjects with violent or criminal behavior, can be considered as a "puzzle" biopsychosocial, that is, with biological psychological and social parts. Although several studies have already evidenced this relationship, it is still a challenge to understand how these pieces fit, or even, how biological processes relate to psychological and social processes.

Thus, it is important to consider the heterogeneity and subjectivity that are associated with the criminal and/or violent act, seeking to evaluate elements such as repentance, empathy, commotion, motivation, chronicity and severity of antisocial behavior. It is believed that these elements may present Indicative data on the need to consider. These aspects for the determination of interventions under the modality of cognitive behavioral therapy during socio and educational measures of hospitalization as well as other mental health contexts.

**89**

**Author details**

Brazil

Prisla Ücker Calvetti1

provided the original work is properly cited.

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

3 Pontifical Catholic University of Rio Grande do Sul—PUCRS, Porto Alegre, Brazil

1 Federal University of Health Sciences of Porto Alegre—UFCSPA, Porto Alegre,

and Gabriel Gauer3

\*, Fernanda de Vargas2

2 Federal University of Santa Maria—UFSM, Santa Maria, Brazil

\*Address all correspondence to: prisla.calvetti@gmail.com

*Neurosciences and Emotional Self-Regulation Applied to Mental Health Contexts*

*DOI: http://dx.doi.org/10.5772/intechopen.83791*

*Neurosciences and Emotional Self-Regulation Applied to Mental Health Contexts DOI: http://dx.doi.org/10.5772/intechopen.83791*

### **Author details**

*Cognitive Behavioral Therapy - Theories and Applications*

adolescents with antisocial behaviors.

specifically, the amygdala, are involved in this capacity [51].

treatment of violence and the crimes present in our society [52].

biological changes that are related to the predisposition to violence.

hospitalization as well as other mental health contexts.

Studies with neuroimaging also find similar results, since the limbic system, more

These results may explain the "coolness" found in the psychopathic conditions, because a lesser capacity to respond adequately to other people's emotions seems be at the root of different behaviors antisocial. Therefore, researches in this field can generate greater understanding about these deficiencies and contribute to the development of interventions of emotional recognition training, among others, in an early way, with the objective of generating greater effectiveness in treatment of

Finally, most studies and theories that sought to understand violence, involved almost in its entirety, social models and sociological, it is noteworthy that neuropsychology is also an area that can contribute in the knowledge criminal behavior. The attention on the anatomical base what involve these behaviors is important for the

In this sense, it is not about denying the importance of the environment in the formation of the subjects, but of recognizing that the social factors are relevant in the development the violent behavior can occur from an interaction with biological aspects. In addition, the experiences experienced in the environment contribute to

Among these biological aspects one can think of genetic factors; hormonal factors; brain factors, both with regard to the structure and the functionality of the cerebrum; among other aspects. From this understanding, the subjects with violent or criminal behavior, can be considered as a "puzzle" biopsychosocial, that is, with biological psychological and social parts. Although several studies have already evidenced this relationship, it is still a challenge to understand how these pieces fit, or even, how biological processes relate to psychological and social processes. Thus, it is important to consider the heterogeneity and subjectivity that are associated with the criminal and/or violent act, seeking to evaluate elements such as repentance, empathy, commotion, motivation, chronicity and severity of antisocial behavior. It is believed that these elements may present Indicative data on the need to consider. These aspects for the determination of interventions under the modality of cognitive behavioral therapy during socio and educational measures of

**88**

Prisla Ücker Calvetti1 \*, Fernanda de Vargas2 and Gabriel Gauer3

1 Federal University of Health Sciences of Porto Alegre—UFCSPA, Porto Alegre, Brazil

2 Federal University of Santa Maria—UFSM, Santa Maria, Brazil

3 Pontifical Catholic University of Rio Grande do Sul—PUCRS, Porto Alegre, Brazil

\*Address all correspondence to: prisla.calvetti@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Gallo AE, Williams LCA. Adolescents in conflict with the law: A review of risk factors for infractional conduct. Psychology Theory and Practice. 2005;**7**(1):81-95

[2] Croat T, McCabe K. The brain and the law. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences. 2004;**29**(359):1727-1736

[3] Buchen L. Arrested development: Neuroscience shows that the adolescent brain is still developing. The question is whether that should influence the sentencing of juveniles. Nature. 2012;**484**:304-306

[4] Galvan A et al. Development of the accumbens relative to orbitofrontal cortex might underlie risk taking behavior in adolescents. The Journal of Neuroscience. 2006;**26**(25):6885-6892

[5] Schwartz JM, Begley S. The Mind & the Brain: Neuroplasticity and the Power of Mental Force. New York: HarperCollins; 2002

[6] Grossman E. Adolescence through the ages. Adolescence Latin American. 1998;**1**:68-74

[7] Osório LC. Teenager Today. Porto Alegre: Medical Arts; 1991

[8] Prates FC. Teen Violator. Curitiba: Juruá; 2002

[9] Piaget J. Six Psychology Studies. 24th ed. Rio de Janeiro: Forensic University; 2003

[10] Lebel C, Walker L, Leemans A, Phillips L, Beaulieu C. Microstructural maturation of the human brain from childhood to adulthood. NeuroImage. 2008;**40**(4):1044-1055

[11] Oliveira PA, Scivoletto S, Cunha PJ. Neuropsychological and neuroimaging associated with emotional stress in childhood and adolescence. Revista de Psiquiatria Clínica. 2010;**37**(6):271-279

[12] Beckman M. Crime, culpability, and the adolescent brain: This fall, the U.S. Supreme Court will consider whether capital crimes by teenagers under 18 should get the death sentence; the case for leniency is based in part on brain studies. Science. 2004;**305**:596-599

[13] Burnett S, Sebastian C, Kadosh KC, Blakemore SJ. The social brain in adolescence: Evidence from functional magnetic resonance imaging and behavioural studies. Neuroscience and Biobehavioral Reviews. 2011;**35**:1654-1664

[14] Haase VG, Salles JF, Miranda MC, Malloy-Dini L, Abreu N, Argollo N, et al. Neuropsychology as interdisciplinary science: Consensus of the Brazilian community of researchers/ clinicians in neuropsychology. Magazine Neuropsychology Latin American. 2012;**4**(4):1-8

[15] Hamdan AC, Pereira APA. Neuropsychological assessment of executive functions: Methodological considerations. Psychology: Research and Review. 2002;**22**(3):386-393

[16] Barros PM, Hazin I. Evaluation of executive functions in childhood: Review of concepts and instruments. Psychological Research. 2013;**7**(1):13-22

[17] Tavares H, Alcarão G. Psychopathology of impulsiveness. In: Abreu CN, Strings TA, Tavares H, editors. Clinical Manual of Impulse Control Disorders. Artmed: Port Merry; 2008

[18] Blair C. Executive Functions in the Classroom. Encyclopedia on the Desen Development in Early

**91**

*Neurosciences and Emotional Self-Regulation Applied to Mental Health Contexts*

[27] Raver CC, Jones SM, Li-Grining CP, Zhai F, Bub K, Pressler E. CSRP's impact on low-income pheschoolers' pre-academic skills: Self-regulation as a mediating mechanism. Child Development. 2011;**82**:362-378

[28] Blair C. Executive Functions in the Classroom. Encyclopedia on Early Childhood Development. 2013. Available from: http:// www.enciclopedia-crianca.com/ sites/default/files/textes-experts/ pt-pt/2474/as-funcoes-executivas-nasala-de-aula.pdf [Accessed: September

[29] Goya-Maldonado R, Walther S, Simon J, Stippich C, Weisbrod M, Kaiser S. Motor impulsivity and the ventrolateral prefrontal cortex. Psychiatry Research: Neuroimaging.

[30] Duncan J, Johnson R, Swales M, Frees C. Frontal lobe deficits after head injury: Unity and diversity of function. Cognitive Neuropsychology.

[31] Fuster J. The prefrontal cortex—An update: Time is of the essence. Neuron.

[32] Seruca TCM. Prefrontal cortex, executive functions and criminal

behavior. PhD thesis in Psychology from the University Institute psychological, Social and life sciences—ISPA. Portugal,

[33] Goldberg E. The Executive Brain.

[34] Consenza RM, War LB. Neuroscience and Education: How the Brain Learns. Porto Alegre: Artmed; 2011

[35] Capovilla AGS, Assef ECS, Cozza HFP. Neuropsychological evaluation of executive functions and relation to attention and hyperactivity. Evaluation

Psychological. 2007;**6**(1):51-60

Rio de Janeiro: Imago; 2002

of 2018]

2010;**183**:89-91

1997;**14**(5):713-741

2001;**30**:319-333

2013

*DOI: http://dx.doi.org/10.5772/intechopen.83791*

Childhood. 2013. Available from: http://www.enciclopedia-crianca. com/sites/default/files/textes-experts/ pt-pt/2474/as-funcoes-executivas-nasala-de-aula.pdf [Accessed: September

[19] Del-Bem CM. Neurobiology of personality anti-social desorder. Revista de Psiquiatria Clínica.

[20] Brandelero V, Toni PM. Test validity study Stroop of colors and words for inhibitory control. Psychology Argument. 2015;**33**(80):282-297

[21] Rossini JC, Macedo LBC, Teobaldo FP. Resolution of labyrinths and task act/not act in the assessment Atentiva. Psychology: Research and Review.

[22] Bilous CF, Piccolo L, Salles JF. Performance of Children from 1st to 6th Grade in a Task of Executive Functions. Available from: https://www.lume. ufrgs.br/bitstream/handle/10183/45652/ Poster\_7194.pdf?sequence=2 [Accessed:

[23] Fuster JM. Frontal lobe and cognitive development. Journal of Neurocytology. 2002;**31**:373-385

[25] Willhelm AR. Evaluation of impulsiveness, inhibitory control and alcohol use in preadolescents and adolescents [master's thesis]. Porto Alegre: Psychology of the University Federal State of Rio Grande do Sul; 2015

Munro S. Preschool program improves cognitive control. Science.

2007;**318**(5855):1387-1388

[26] Diamond A, Barnett WS, Thomas J,

[24] Miranda MC, Muszkat M. Neuropsychologistsa development. In: Andrade VM, Santos FH, Bueno OFA, editors. Neuropsychology Today. São Paulo: Medical Arts; 2004. pp. 211-224

of 2018]

2005;**32**(1):27-36

2015;**28**(4):796-803

August of 2018]

*Neurosciences and Emotional Self-Regulation Applied to Mental Health Contexts DOI: http://dx.doi.org/10.5772/intechopen.83791*

Childhood. 2013. Available from: http://www.enciclopedia-crianca. com/sites/default/files/textes-experts/ pt-pt/2474/as-funcoes-executivas-nasala-de-aula.pdf [Accessed: September of 2018]

[19] Del-Bem CM. Neurobiology of personality anti-social desorder. Revista de Psiquiatria Clínica. 2005;**32**(1):27-36

[20] Brandelero V, Toni PM. Test validity study Stroop of colors and words for inhibitory control. Psychology Argument. 2015;**33**(80):282-297

[21] Rossini JC, Macedo LBC, Teobaldo FP. Resolution of labyrinths and task act/not act in the assessment Atentiva. Psychology: Research and Review. 2015;**28**(4):796-803

[22] Bilous CF, Piccolo L, Salles JF. Performance of Children from 1st to 6th Grade in a Task of Executive Functions. Available from: https://www.lume. ufrgs.br/bitstream/handle/10183/45652/ Poster\_7194.pdf?sequence=2 [Accessed: August of 2018]

[23] Fuster JM. Frontal lobe and cognitive development. Journal of Neurocytology. 2002;**31**:373-385

[24] Miranda MC, Muszkat M. Neuropsychologistsa development. In: Andrade VM, Santos FH, Bueno OFA, editors. Neuropsychology Today. São Paulo: Medical Arts; 2004. pp. 211-224

[25] Willhelm AR. Evaluation of impulsiveness, inhibitory control and alcohol use in preadolescents and adolescents [master's thesis]. Porto Alegre: Psychology of the University Federal State of Rio Grande do Sul; 2015

[26] Diamond A, Barnett WS, Thomas J, Munro S. Preschool program improves cognitive control. Science. 2007;**318**(5855):1387-1388

[27] Raver CC, Jones SM, Li-Grining CP, Zhai F, Bub K, Pressler E. CSRP's impact on low-income pheschoolers' pre-academic skills: Self-regulation as a mediating mechanism. Child Development. 2011;**82**:362-378

[28] Blair C. Executive Functions in the Classroom. Encyclopedia on Early Childhood Development. 2013. Available from: http:// www.enciclopedia-crianca.com/ sites/default/files/textes-experts/ pt-pt/2474/as-funcoes-executivas-nasala-de-aula.pdf [Accessed: September of 2018]

[29] Goya-Maldonado R, Walther S, Simon J, Stippich C, Weisbrod M, Kaiser S. Motor impulsivity and the ventrolateral prefrontal cortex. Psychiatry Research: Neuroimaging. 2010;**183**:89-91

[30] Duncan J, Johnson R, Swales M, Frees C. Frontal lobe deficits after head injury: Unity and diversity of function. Cognitive Neuropsychology. 1997;**14**(5):713-741

[31] Fuster J. The prefrontal cortex—An update: Time is of the essence. Neuron. 2001;**30**:319-333

[32] Seruca TCM. Prefrontal cortex, executive functions and criminal behavior. PhD thesis in Psychology from the University Institute psychological, Social and life sciences—ISPA. Portugal, 2013

[33] Goldberg E. The Executive Brain. Rio de Janeiro: Imago; 2002

[34] Consenza RM, War LB. Neuroscience and Education: How the Brain Learns. Porto Alegre: Artmed; 2011

[35] Capovilla AGS, Assef ECS, Cozza HFP. Neuropsychological evaluation of executive functions and relation to attention and hyperactivity. Evaluation Psychological. 2007;**6**(1):51-60

**90**

*Cognitive Behavioral Therapy - Theories and Applications*

and neuroimaging associated with emotional stress in childhood and adolescence. Revista de Psiquiatria

[12] Beckman M. Crime, culpability, and the adolescent brain: This fall, the U.S. Supreme Court will consider whether capital crimes by teenagers under 18 should get the death sentence; the case for leniency is based in part on brain studies. Science. 2004;**305**:596-599

[13] Burnett S, Sebastian C, Kadosh KC, Blakemore SJ. The social brain in adolescence: Evidence from functional magnetic resonance imaging and behavioural studies. Neuroscience and Biobehavioral Reviews.

[14] Haase VG, Salles JF, Miranda MC, Malloy-Dini L, Abreu N, Argollo N,

interdisciplinary science: Consensus of the Brazilian community of researchers/ clinicians in neuropsychology. Magazine Neuropsychology Latin American.

Clínica. 2010;**37**(6):271-279

2011;**35**:1654-1664

2012;**4**(4):1-8

et al. Neuropsychology as

[15] Hamdan AC, Pereira APA. Neuropsychological assessment of executive functions: Methodological considerations. Psychology: Research and Review. 2002;**22**(3):386-393

[16] Barros PM, Hazin I. Evaluation

childhood: Review of concepts and instruments. Psychological Research.

[17] Tavares H, Alcarão G. Psychopathology of impulsiveness. In: Abreu CN, Strings TA, Tavares H, editors. Clinical Manual of Impulse Control Disorders. Artmed: Port Merry; 2008

[18] Blair C. Executive Functions in the Classroom. Encyclopedia on the Desen Development in Early

of executive functions in

2013;**7**(1):13-22

[1] Gallo AE, Williams LCA. Adolescents in conflict with the law: A review of risk factors for infractional conduct. Psychology Theory and Practice.

[2] Croat T, McCabe K. The brain and the law. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences. 2004;**29**(359):1727-1736

[3] Buchen L. Arrested development: Neuroscience shows that the adolescent brain is still developing. The question is whether that should influence the sentencing of juveniles. Nature.

[4] Galvan A et al. Development of the accumbens relative to

orbitofrontal cortex might underlie risk taking behavior in adolescents. The Journal of Neuroscience. 2006;**26**(25):6885-6892

[5] Schwartz JM, Begley S. The Mind & the Brain: Neuroplasticity and the Power of Mental Force. New York:

[6] Grossman E. Adolescence through the ages. Adolescence Latin American.

[7] Osório LC. Teenager Today. Porto

[8] Prates FC. Teen Violator. Curitiba:

[9] Piaget J. Six Psychology Studies. 24th ed. Rio de Janeiro: Forensic University;

[10] Lebel C, Walker L, Leemans A, Phillips L, Beaulieu C. Microstructural maturation of the human brain from childhood to adulthood. NeuroImage.

2008;**40**(4):1044-1055

[11] Oliveira PA, Scivoletto S, Cunha PJ. Neuropsychological

Alegre: Medical Arts; 1991

**References**

2005;**7**(1):81-95

2012;**484**:304-306

HarperCollins; 2002

1998;**1**:68-74

Juruá; 2002

2003

[36] Gooch D, Snowling M, Hulme C. Time perception, phonological skills and executive function in children with dyslexia and/or ADHD symptoms. Journal of Child Psychology and Psychiatry, and Allied Disciplines. 2011;**52**(2):195-203

[37] Teixeira VPG. Changes in Executive Functions, Impulsiveness and Aggressiveness in Crack-Dependent Individuals. Alagoas: SayMaster's degree in psychology from University Federal de Alagoas; 2014

[38] Raine A, Buchsbaum M, Lacasse L. Brain abnormalities in murderes indicated by positron emission tomography. Biological Psychiatry. 1997;**42**:495-508

[39] Gomes CC, Almeida RMM. Psychopathy in men and women. Brazilian Archives of Psychology. 2010;**62**(1):13-21

[40] Jozef F, Silva JAR, Greenhalgh S, Leite MEL, Ferreira VH. Violent behavior and cerebral dysfunction: A study of homicides in Rio de Janeiro. Revista Brasileira Psychiatry. 2000;**22**(3):124-129

[41] Vasconcellos SJL. The Good, the Evil and the Sciences of the Mind: Of What Psychopaths Are Constituted. São Paulo: Icon; 2014

[42] Patrick CJ, Fowles DC, Krueger RF. Triarchic conceptualization of psychopathy: Developmental origins of disinhibition, boldness, and meanness. Development and Psychopathology. 2009;**21**(3):913-938

[43] Blair RJR. The cognitive neuroscience of psychopathy and implications for judgments of responsibility. Neuroethics. 2008;**1**:149-157

[44] Blair RJR, Coles M. Expression recognition and behavioral problems in early adolescence. Cognitive Development. 2000;**15**:421-434

[45] Blair RJR, Colledge E, Murray L, Mitchell DG. A selective impairment in the processing of sad and fearful expressions in children with psychopathic tendencies. Journal of Abnormal Child Psychology. 2001;**29**:491-498

[46] Stevens D, Charman T, Blair RJ. Recognition of emotion in facial expressions and vocal tones in children with psychopathic tendencies. Journal of Genetic Psychology. 2001;**162**:201-211

[47] Dadds MR, Perry Y, Hawes DJ, Merz S, Riddell AC, Haines DJ, et al. Attention to the eyes and fear-recognition deficits in child psychopathy. British Journal of Psychiatry. 2006;**189**:180-181

[48] Iria C, Barbosa F, Passion R. The identification of negative emotions through a go/No-go task: Comparative research in criminal and non-criminal psychopaths. European Psychologist. 2012;**17**(4):291-299

[49] Vasconcellos SJL, Salvador-Silva R, Gauer V, Gauer GCJ. Psychopathic traits in adolescents and recognition of emotion in facial expressions. Psychology: Research and Review. 2014;**27**(4):768-774

[50] Eisenbarth H, Alpers GW, Segrè D, Calogero A, Angrilli A. Perception and evaluation of emotional faces in women scoring high on psychopathy. Psychiatry Research. 2008;**159**(1-2):189-195

[51] Moul C, Killcross S, Dadds MR. A model of differential amygdala activation in psychopathy. Psychological Review. 2012;**119**(4):789-806

[52] Raine A. The Anatomy of Violence—The Biological Roots of Crime. Porto Alegre: Artmed; 2015

*Cognitive Behavioral Therapy - Theories and Applications*

in early adolescence. Cognitive Development. 2000;**15**:421-434

2001;**29**:491-498

2001;**162**:201-211

2012;**17**(4):291-299

2014;**27**(4):768-774

[45] Blair RJR, Colledge E, Murray L, Mitchell DG. A selective impairment in the processing of sad and fearful expressions in children with psychopathic tendencies. Journal of Abnormal Child Psychology.

[46] Stevens D, Charman T, Blair RJ. Recognition of emotion in facial expressions and vocal tones in children

[47] Dadds MR, Perry Y, Hawes DJ, Merz S, Riddell AC, Haines DJ, et al. Attention to the eyes and fear-recognition deficits in child psychopathy. British Journal of

with psychopathic tendencies. Journal of Genetic Psychology.

Psychiatry. 2006;**189**:180-181

[48] Iria C, Barbosa F, Passion R. The identification of negative emotions through a go/No-go task: Comparative research in criminal and non-criminal psychopaths. European Psychologist.

[49] Vasconcellos SJL, Salvador-Silva R, Gauer V, Gauer GCJ. Psychopathic traits in adolescents and recognition of emotion in facial expressions. Psychology: Research and Review.

[50] Eisenbarth H, Alpers GW, Segrè D, Calogero A, Angrilli A. Perception and evaluation of emotional faces in women scoring high on psychopathy. Psychiatry

Research. 2008;**159**(1-2):189-195

Review. 2012;**119**(4):789-806

[52] Raine A. The Anatomy of Violence—The Biological Roots of Crime. Porto Alegre: Artmed; 2015

[51] Moul C, Killcross S, Dadds MR. A model of differential amygdala

activation in psychopathy. Psychological

[36] Gooch D, Snowling M, Hulme C. Time perception, phonological skills and executive function in children with dyslexia and/or ADHD symptoms. Journal of Child Psychology and Psychiatry, and Allied Disciplines.

[37] Teixeira VPG. Changes in Executive

[38] Raine A, Buchsbaum M, Lacasse L. Brain abnormalities in murderes indicated by positron emission tomography. Biological Psychiatry.

[39] Gomes CC, Almeida RMM. Psychopathy in men and women. Brazilian Archives of Psychology.

[40] Jozef F, Silva JAR, Greenhalgh S, Leite MEL, Ferreira VH. Violent behavior and cerebral dysfunction: A study of homicides in Rio de Janeiro. Revista Brasileira Psychiatry.

[41] Vasconcellos SJL. The Good, the Evil and the Sciences of the Mind: Of What Psychopaths Are Constituted. São Paulo:

[42] Patrick CJ, Fowles DC, Krueger RF.

psychopathy: Developmental origins of disinhibition, boldness, and meanness. Development and Psychopathology.

Triarchic conceptualization of

[43] Blair RJR. The cognitive neuroscience of psychopathy and implications for judgments of responsibility. Neuroethics.

[44] Blair RJR, Coles M. Expression recognition and behavioral problems

Functions, Impulsiveness and Aggressiveness in Crack-Dependent Individuals. Alagoas: SayMaster's degree in psychology from University Federal

2011;**52**(2):195-203

de Alagoas; 2014

1997;**42**:495-508

2010;**62**(1):13-21

2000;**22**(3):124-129

2009;**21**(3):913-938

2008;**1**:149-157

Icon; 2014

**92**

### *Edited by Sandro Misciagna*

Cognitive behavioral therapy (CBT) is a modern type of short-term psychotherapy that integrates cognitive and behavioral theories. The CBT approach is effective in the treatment of a wide range of mental issues and conditions, such as generalized anxiety disorders, general or post-traumatic stress, panic attacks, depression, eating and sleep dysfunctions, obsessive–compulsive disorders, and substance dependence. CBT is also effective as an intervention for psychotic, personality, and bipolar disorders or to approach fatigue and chronic pain conditions especially if associated with distress. This book explains both theoretical and practical aspects of CBT, along with case examples, and contains useful tools and specific interventions for different psychological situations.

Published in London, UK © 2020 IntechOpen © Eleni Mac Synodinos / iStock

Cognitive Behavioral Therapy - Theories and Applications

Cognitive Behavioral Therapy

Theories and Applications

*Edited by Sandro Misciagna*