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CPSY 265, Body Dysmorphic Disorder, Winter 07 Gregg Williams
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Cognitive Behavioral Therapy and Body Dysmorphic Disorder
Gregg Williams
Body dysmorphic disorder (BDD) is a type of somatoform disorder in which a person is preoc-cupied with an "imagined defect in appearance" or has a "markedly excessive" concern about a slightphysical anomaly, to the point that the person has "clinically significant distress or impairment in so-cial, occupational, or other important areas of function" (American Psychiatric Association, 2000). Re-ports of the rate of BDD in the general population range from 0.7 to 2.3 percent, with one outlying re-port of 13% (Phillips and Castle, 2002). The male-to-female ratio for people with BDD is approxi-mately 1:1 (Wilhelm and Neziroglu, 2002). Phillips and Castle (2002) reported that "the disorder'sclinical features appeared generally similar in men and women."Characteristics of BDDBDD usually begins during adolescence. Phillips and Castle (2002) reported that research todate showed "a mean age of onset of 16 and a mode of 13." The largest single study of children andadolescents reported suicidal ideation in 67% of the subjects, psychiatric hospitalization in 39%, vio-lent behavior in 30%, and suicide attempts "due to BDD symptoms" in 21%. However, BDD "tends tobe chronic, often enduring for decades without remission" (Wilhelm and Neziroglu, 2002).Albertini and Phillips' 1999 study of 33 children and adolescents with BDD (cited in Hadley,Greenberg, and Hollander, 2002) provides additional data about the characteristics of adolescent BDD.Although any body part can be the focus of BDD, the adolescents in the study most often focused ontheir skin (61% of sample) or their hair (55%). Of the total child and adolescent sample, "94% had asignificant impairment in functioning that included academic failure, job impairments, and social isola-
CPSY 265, Body Dysmorphic Disorder, Winter 07 Gregg Williams
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tion" (Hadley
et al.
, 2002). Because BDD is itself such a strong marker for other impairments, it is rec-ommended that clinicians screen for it by asking child and adolescent clients if they have "any con-cerns about their appearance"; such clients are so embarrassed or ashamed of their appearance that theywill often and not be able to name a specific body part as the focus of their anxiety.
Behaviors
According to Rosen (1998), "The most consistent feature [of people with BDD] is avoidance of social situations, usually because the patient expects that negative attention will be drawn to his or herappearance." However, they are usually capable of limited functioning "by wearing clothes, grooming,or contorting body posture movements in such a way as to hide the defect."Wilhelm and Neziroglu (2002) observed that "About 90% of the individuals suffering fromBDD perform repetitive behaviors intended to check, improve, or hide the supposed defect." Repetitivebehaviors "can consume several hours per day and usually only provide temporary relief"; they include"checking the perceived flaw in mirrors or other reflecting surfaces," attempting to "camouflage theperceived flaw with makeup, hair, body position, or clothing," "excessive grooming behaviors," and"compar[ing] their appearance with that of other people." In some cases, people with BDD "pick attheir skin for several hours per day, trying to remove blemishes," even when such behavior results inmedical problems or disfigurement.Other behaviors include asking others for reassurance about their appearance and avoidingsituations that are brightly lighted (Wilhelm and Neziroglu, 2002).
CPSY 265, Body Dysmorphic Disorder, Winter 07 Gregg Williams
3 of 13Cognitions
People with BDD tend to have certain thoughts about the appearance of certain body parts, aswell as additional thoughts about how others see them. These include:
•
a preoccupation with "the idea that some aspect of their appearance is unattractive,deformed, ugly, or 'not right'" (Phillips and Castle, 2002)
•
a belief that "others share their view of the perceived defect...take notice and are dis-gusted by it (Wilhelm and Neziroglu, 2002)
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a belief that "the perceived defect reveals some personal flaw and is indicative of their self-worth" (Wilhelm and Neziroglu, 2002)
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a conviction that, because of these thoughts, "the only way to improve their self-esteem is to improve the way they look" (Rosen, 1998)This last belief contributes to the tenacity of BDD. Unfortunately, for people with BDD, thedistortion is in their internal body image (Veale, 2002). As a result, no amount of change or camou-flage to the person's physical body will be satisfying, and the person will be continually dissatisfiedand continually driven to take additional actions in pursuit of decreasing the resulting anxiety.
Level of Insight
Multiple sources have reported that many people with BDD so firmly believe "with absoluteconviction that the flaw they perceive is actually noticeable and ugly" (Wilhelm and Neziroglu, 2002)that they are delusional. Phillips and Castle (2002) put the population of delusional BDD patients asbeing 50% of the total BDD population. Wilhelm and Neziroglu, among others, believe that such peo-ple should be given an additional diagnosis of delusional disorder, somatic type. More recently,
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