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*Dr. Phillips is Professor of Psychiatry at Brown Medical School and Director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence, Rhode Island. Dr. Phillips has been doing research and treating patients with BDD since 1990, which has involved approximately 800 individuals with this disorder. Her pioneering work, which has focused largely on BDD's psychopathology and pharmacological treatment, has brought this disorder to the attention of the public and professionals alike. She has written and edited several books on BDD and body image, including The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (Phillips 1996).
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* K# l1 j4 \+ K" C& q! C1 _**Dr. Crino is Senior Lecturer in the School of Psychiatry at the University of New South Wales and Director of the Anxiety Disorders Unit at St. Vincent's Hospital in Sydney, Australia. Since 1988, Dr. Crino has worked extensively in the treatment of Obsessive-Compulsive Disorder and related conditions. In 1999, he established a cognitive-behavioral treatment program for BDD. He has published pa-pers in the area of anxiety and related disorders and is coauthor of The Treatment of Anxiety Disorders (Cambridge University Press, 1994).5 X3 ?5 [* W5 ]( r" ~, W( n- B4 I1 O

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Hollander E, Allen A, Kwon J, et al: Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness. Arch Gen Psychiatry 56:1033–1039, 1999  [PubMed]
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Marks IM, Mishan J: Dysmorphophobic avoidance with disturbed bodily perception: a pilot study of exposure therapy. Br J Psychiatry 152:674–678, 1988  [PubMed]
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Neziroglu F, Khemlani-Patel S: A review of cognitive and behavioral treatment for body dysmorphic disorder. CNS Spectrums 7:464–471, 2002  [PubMed]
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A 35-year-old African American woman, Sheila Joyner, was brought to the psychiatric emergency room at the request of the pediatrician examining her 14-month-old baby, Rasheed. Ms. Joyner had first brought her child to see a pediatrician 2 weeks earlier, when the baby's grandmother complained that a diet consisting largely of breast milk was not appropriate for a child of that age. The pediatrician prescribed iron and scheduled a follow-up appointment. When Ms. Joyner reported at follow-up that she had not given her son iron, the pediatrician, concerned because the baby had lost an additional 2 pounds, arranged for the baby to be hospitalized, even though the mother objected. Three security guards were required to wrest the baby from his sobbing mother; and when she began to threaten the staff with a lawsuit, saying the doctors were going to "poison" her baby, Ms. Joyner was brought to the adult psychiatric emergency room, where she spent the night.' G7 w7 \8 D# M' q- E1 n) F
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The following morning, Ms. Joyner appeared calm but guarded throughout the psychiatric interview. She refused to shake the examiner's hand, explaining that she had just washed her hands in preparation for a snack. She denied any compulsion to wash or obsession with cleanliness. Ms. Joyner reported graduating from college and having taught elementary school until her only child was born, fathered by a friend who lived in another city. Her pregnancy was undetected until 5 months of gestation and complicated by severe anemia. She had had anemia 10 years earlier, but had then refused medical care. She reported curing it herself, by learning to live in a more "natural manner," walking in parks rather than near buildings, and eating only natural foods and "purified" water. This lifestyle, she explained, enabled her to produce a perfectly healthy baby even though her obstetrician had told her that she herself had severe anemia.  u1 i3 f9 [' o1 U3 \
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Ms. Joyner explained that she had refused to feed her baby "nonorganic" iron as prescribed by the pediatrician and insisted on giving him only breast milk because she wanted to provide him with the same diet that had been so good for her. She did not have Rasheed vaccinated, as this was "unnatural," and she supported these views by referring to books and pamphlets from organizations promoting "natural" approaches to health, as well as to discussions with friends who shared these views. Her arguments, although based on questionable data, were understandable and internally consistent. At no time did she show evidence of tangential or disorganized speech, and she appeared quite intelligent.8 Y3 N/ Q$ q: A" z0 ^: }! ?& B
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The psychiatrist tried to explain that Rasheed's anemia was serious and that he was at risk for permanent neurological damage. Ms. Joyner responded by saying that the same treatment that had been good for her would protect her baby. When the doctor explained the ways in which an infant's needs were different from an adult's, she stated that, just as the doctors had been wrong about treating her anemia in the past, the psychiatrist was now wrong about her child. Ms. Joyner clung to her position regarding the danger of "nonorganic" iron, citing as evidence the stomach upset she had experienced when she had taken iron. If given the choice between losing her child and being forced to feed him iron, she would rather lose him, as she did not want any part of "poisoning" her baby.3 {}4 M
The psychiatrist met with Ms. Joyner once again and explained the severity of her baby's condition. She countered that the standards used to measure her baby were "Western" and not appropriate for a baby with "African genes." As the medical condition of the baby deteriorated, the pediatric staff turned to legal counsel and the Bureau of Child Welfare; both suggested treating the baby against the mother's will.
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DSM-IV-TR Casebook Diagnosis of "An Iron Will"
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& u. [8 @% I( f; k4 l. X  o9 mThere can be no disagreement that Rasheed needs to receive medical care if he is to survive. However, it is less clear how one should understand his mother's stubborn insistence that he be given no "unnatural" medication. Does her belief that "unnatural" medicines and foods are poisonous constitute a delusion? If so, the diagnosis would be Delusional Disorder, Persecutory Type. In favor of such a diagnosis is the extreme degree to which she acts on her beliefs even in the face of evidence that doing so has terrible consequences for her son. Her statement that she had treated her own anemia by avoiding walking near buildings suggests an idiosyncratic approach to medical treatment that is unlikely to be found in any of her pamphlets. On the other hand, she has been influenced by nontraditional views of medicine and health that are espoused by a vocal minority.' g: B+ Y9 E" ^" ?* T! g& V
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