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Katharine Phillips '87: Shedding light on BDD
By Laura Stephenson Carter

When Katharine Phillips was a third-year psychiatry resident at McLean Hospital in Belmont, Mass, in 1990, she started seeing patients who were tormented by seemingly nonexistent problems. "These patients were so memorable and so striking, their symptoms were fascinating to me," she says. "They were so debilitated by them, that I was really astounded."

One male patient was severely depressed because he was convinced that his hair was falling out and that he looked horrible. "This was a guy who was really very impaired," Phillips says. "He had quit his job. He was not in a relationship because of his hair. I'm thinking, 'He thinks something's wrong with his hair. He looks fine. How could this possibly cause his life to completely unravel and make him barely able to function?'"

Phillips (above) and her two books (next image) have done much to raise awareness of body dysmorphic disorder.

Phillips saw a few more patients like this. "Sometimes their stories were very bizarre," she says. "Patients who would try to do their own surgery on themselves because they thought they didn't look right. One guy broke into houses across the country so he could get enough money to go to California to get plastic surgery because he though he didn't look right. He was actually very handsome. I was struck by the suffering and by how fascinating some of these stories were."

Puzzled by the mysterious symptoms, Phillips checked the Diagnostic and Statistical Manual of Mental Disorders, known as the DSM, in the hope of finding an explanation. She found a reference to a syndrome called body dysmorphic disorder (BDD).

"I had never heard of body dysmorphic disorder, never," she says. Neither had more of her supervisors. "It had not been mentioned in medical school. I'd done a fair amount of reading in psychiatry by that point — never seen it mentioned once. I'd not had a lecture on it in my residency, but it was in DSM

So Phillips reviewed the literature. "It was clear that this was not a new disorder. It had been described for over a century. I thought, 'This is very interesting that this disorder has somehow fallen through the cracks of modern-day psychiatry.'"

Since then, she has done more than anyone to educate the world about BDD, a disorder in which sufferers - as many as one in 50 people, men as well as women - are obsessed with imagined flaws in their appearance. In 1990, as a Burroughs-Wellcome Fellow for the American Psychiatric Association (APA), she gave her first public presentation on BDD at the APA annual meeting. The following year, she really put BDD on the map when her review of the literature appeared as the cover article in the American Journal of Psychiatry.

Body dysmorphic disorder was "one of those things nobody noticed," says Harrison Pope, M.D., a professor of psychiatry at Harvard Medical School and one of Phillips's mentors. "She's woken up the world to the problem."

It's a problem that had perplexed dermatologists, emergency room doctors, surgeons, and other physicians, who often had to deal with the consequences of patients who had practically butchered themselves in their desperate attempts to achieve perfection.

There was a case of "a woman who picked at a pimple on her neck and couldn't stop," says Phillips. "She had BDD. She thought it didn't look right - it shouldn't be there. She had to get rid of it and she couldn't stop, as they often can't, and was picking with tweezers and exposed her carotid artery. She needed emergency surgery and almost died. The surgeon said if she'd been a millimeter more lateral, she wouldn't have survived - she would have picked into the artery. Features of the illness like this had never been described before." Phillips coauthored an article about this particular case for the journal Psychosomatics in 1999.

She has also published two books on the subject - The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder and The Adonis Complex: The Secret Crisis of Male Body Obsession, which she coauthored with Pope and Harvard psychologist Roberto Olivardia, Ph.D.

Though Phillips has become one of the world's leading authorities on a devastating psychiatric disorder, she almost didn't become a doctor. She was a psychology major at Dartmouth because, "I was always interested in what made people tick," but she shied away from taking most premed courses. "General chemistry and calculus seemed pretty far removed from taking care of patients," she says, "and [from] what people think and feel."

Instead, when she graduated from Dartmouth in 1977, she entered publishing. She worked in New York City, editing books for Macmillan - including the Beverly Hills Diet, she laughs - and later for Fisher Medical Publications. She also wrote for magazines, including Woman's World and Vogue. But it wasn't long before she returned to the Upper Valley, where she became the communications coordinator for the Norris Cotton Cancer Center (NCCC) at DHMC.

"I wrote their newspaper column on cancer," she says. "I did their newsletter, and I wrote about the research that the oncologists were doing at the Cancer Center." In fact, one of her articles appeared in the Fall 1981 issue of this magazine.

"As our embryonic cancer center was launched, it was clear that we needed someone on board with editorial skills and the ability to communicate effectively," says Ross McIntyre, M.D., director of the NCCC from 1975 to 1992. "Kathy appeared out of the blue and was a wonderful member of the team as the Cancer Center worked toward its early goals."

"The were terrific people who obviously cared a lot about their patients. . . and also did this incredibly fascinating research and moved the field forward," Phillips says. She longed to do more than just write about medicine and decided to become a doctor. "I thought, 'What better job could anyone have?'"

Phillips spent her first year of medical school at the University of Rochester, then transferred to DMS. As part of her training at Dartmouth, she did psychosocial research with a faculty member, an elective in psychopharmacology research at the National Institute of Mental Health, and a primary-care clerkship on a Navajo reservation in Tuba City, Ariz.

Medical school "was better than I expected, especially the clinical part," says Phillips. "I think Dartmouth was a great place to go, because the training was already quite clinically focused, even as early as the second year. For me that was a great fit, because a lot of my interest was clinical and seeing patients."

One DMS faculty member who may not have realized he was making an impression on Phillips was pharmacologist David Nierenberg, M.D., now associate dean for medical education. "I thought he was just wonderful," Phillips says. "He was a superb lecturer. I sat there in his lectures with two tracks going in my mind. One was learning the pharmacology that he was lecturing about. The other was taking mental note of how he put his lectures together and what made him such a great lecturer. He provided the cornerstone for my learning how to give a talk and lecture."

Phillips didn't expect Nierenberg to remember her after all these years. But, he says, "actually, I remember Katharine Phillips very well, even though that was 14 years ago. Each year there are many wonderful students in each class, but there are sometimes two or three who really stand out because of their intellectual sharpness, or warm personality, or passion for patient care. Those are the ones you remember instantly, even after 14 years. Katharine stood out in all of those areas. It was very clear to me from her time at DMS that she was going to be a very excellent and supportive clinician who would make an impact eventually on her chosen discipline."

And Phillips certainly has made an impact. Today, she is one of the foremost authorities on body dysmorphic disorder. In addition to her books, she has published more than 200 articles on the topic, and she has made nearly 300 presentations all over the world. Thanks to her efforts, much progress has been made in recognizing and diagnosing BDD. But she believes it will be along time before anyone truly understands what causes the disorder.

Determining "the cause of BDD is the final frontier," she says. "Like every psychiatric disorder, there's a complex mix of pathophysiologic and etiologic factors."

It has become apparent that people with BDD have an abnormality in their levels of serotonin, a type of neurotransmitter in the brain, because serotonin reuptake inhibitors (SSRIs) seem to mitigate BDD symptoms. SSRIs are a class of medications used to treat mild to moderate depression or other affective disorders, including obsessive-compulsive disorder, anxiety, and bulimia.

Environmental factors and sociocultural messages might play a role too, Phillips says. It's possible that people are more likely to develop BDD if they were teased as kids, told they were ugly, or rejected, or if they are temperamentally sensitive, self-conscious, shy, and anxious. And maybe there's an evolutionary basis as well. "We know that appearance is important in the animal world," she says. "Symmetry, for example, signifies reproductive health and fitness." But there's no proof yet that that's the case in humans, too.

In her current research, Phillips is exploring whether people with BDD process visual images differently: Are they more sensitive to visual stimuli, for example, so they overmagnify imperfections? Are there deficits in the way they process visual stimuli? Are they seeing things normally but evaluating them differently?

"Some patients say, 'I feel like I'm looking at myself under a magnifying glass,'" Phillips explains. "You wonder if they have even more sensitive visual processes - they're more sensitive than we are - but it's unclear. It's interesting, though, that when you treat some of them with medication, these patients will clearly state that the medication has changed their vision - medications like . . . the serotonin reuptake inhibitors. They will say things like, 'I look completely different.' 'I look normal now.' 'I don't look like a monster anymore.'"

In addition to continuing her research, Phillips sees patients, most of whom have BDD, in her Providence, R.I., office. She also provides emergency room coverage, seeing people with a broad range of psychiatric problems. Her home life has a medical spin to it, too: she's married to child psychiatrist Ralph Albertini, M.D., a Dartmouth housestaff alum (1973-78), who collaborates with her on some of her research.

Phillips is full of compassion for the people who are suffering from this underrecognized disorder. "I'm proudest of the fact that I've done work that has really made a difference in people's lives, and . . . that some people, if not many, are living better lives because of this work," says Phillips. "That is extremely gratifying. It's really nice to open a letter from someone [saying] that you have made a difference in their life."

Laura Carter is the associate editor of Dartmouth Medicine magazine.

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