CPSY 265, Body Dysmorphic Disorder, Winter 07

Gregg Williams

Cognitive Behavioral Therapy and Body Dysmorphic Disorder
Gregg Williams Body dysmorphic disorder (BDD) is a type of somatoform disorder in which a person is preoccupied with an "imagined defect in appearance" or has a "markedly excessive" concern about a slight physical anomaly, to the point that the person has "clinically significant distress or impairment in social, occupational, or other important areas of function" (American Psychiatric Association, 2000). Reports of the rate of BDD in the general population range from 0.7 to 2.3 percent, with one outlying report of 13% (Phillips and Castle, 2002). The male-to-female ratio for people with BDD is approximately 1:1 (Wilhelm and Neziroglu, 2002). Phillips and Castle (2002) reported that "the disorder's clinical features appeared generally similar in men and women." Characteristics of BDD BDD usually begins during adolescence. Phillips and Castle (2002) reported that research to date showed "a mean age of onset of 16 and a mode of 13." The largest single study of children and adolescents reported suicidal ideation in 67% of the subjects, psychiatric hospitalization in 39%, violent behavior in 30%, and suicide attempts "due to BDD symptoms" in 21%. However, BDD "tends to be 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 on their skin (61% of sample) or their hair (55%). Of the total child and adolescent sample, "94% had a significant impairment in functioning that included academic failure, job impairments, and social isola1 of 13

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tion" (Hadley et al., 2002). Because BDD is itself such a strong marker for other impairments, it is recommended that clinicians screen for it by asking child and adolescent clients if they have "any concerns about their appearance"; such clients are so embarrassed or ashamed of their appearance that they will 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 her appearance." 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 from BDD perform repetitive behaviors intended to check, improve, or hide the supposed defect." Repetitive behaviors "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 the perceived 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 at their skin for several hours per day, trying to remove blemishes," even when such behavior results in medical problems or disfigurement. Other behaviors include asking others for reassurance about their appearance and avoiding situations that are brightly lighted (Wilhelm and Neziroglu, 2002).

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Cognitions People with BDD tend to have certain thoughts about the appearance of certain body parts, as well 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 disgusted by it (Wilhelm and Neziroglu, 2002) • a belief that "the perceived defect reveals some personal flaw and is indicative of their self-worth" (Wilhelm and Neziroglu, 2002) • a conviction that, because of these thoughts, "the only way to improve their selfesteem is to improve the way they look" (Rosen, 1998) This last belief contributes to the tenacity of BDD. Unfortunately, for people with BDD, the distortion is in their internal body image (Veale, 2002). As a result, no amount of change or camouflage to the person's physical body will be satisfying, and the person will be continually dissatisfied and 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 absolute conviction 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 as being 50% of the total BDD population. Wilhelm and Neziroglu, among others, believe that such people should be given an additional diagnosis of delusional disorder, somatic type. More recently,

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though, additional evidence has led Rossell and Castle (2006) to say, "There is also good reason to accept that the degree of delusionality of belief associated with BDD should be considered a spectrum, rather than viewing delusional and nondelusional forms as being categorically different"; this would argue against a separate diagnosis of delusional disorder. Comorbidity with Other Diseases More often than not, BDD is comorbid with other psychological disorders. According to Philips and Castle (2002), the most common disorders found to be comorbid with BDD are major depression (current rate of 60%, lifetime rate of over 80%), social phobia (lifetime rate of 38%), substance abuse disorders (lifetime rate of 36%), and OCD (lifetime rate of 30%); within the BDD population, rates of attempted suicide as high as 30% have been reported. In the case of depression, BDD occurs first, and depression is seen as secondary to the depression. BDD patients seen in psychiatric settings have often been found to have a personality disorder; studies report comorbidity rates of 57% to 100%, with avoidant personality disorder being the most common. Factors influencing differential diagnosis Because BDD is not a well-known disease, it is often misdiagnosed. Possible misdiagnoses include obsessive-compulsive disorder (OCD), eating disorders, depression, social phobia, agoraphobia, panic disorder, trichtotillomania, schizophrenia, and psychotic disorder NOS (Phillips and Castle, 2002). BDD can be distinguished from various eating disorders in several ways. BDD is characterized by a distorted perception of a specific body part, which the person may attempt to camouflage, whereas eating disorders are characterized by a distorted perception of overall body shape and, possibly, at4 of 13

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tempts to camouflage the entire body. BDD results in the behavior of avoiding social interactions, while eating disorders result in food-related behaviors (e.g., bingeing and purging). Finally, each disorder has its own characteristic excess: People with BDD may seek unnecessary cosmetic surgeries, while people with eating disorders often engage in excessive exercise (Slaughter and Sun, 1999). Treatments for BDD As of this writing, little can definitively be said about the efficacy of various treatments for BDD. Established researchers specializing in BDD have commented that the numerous "limitations of the published literature" (including "a paucity of randomized controlled trials") have hampered comparing the efficacies of various treatments (Castle and Rosell, 2006). In fact, Castle and Rosell were able to summarize the existing knowledge on the subject by saying that "it seems reasonable to conclude that behavioral therapy or CBT are the preferred psychological approaches, and that SRIs [serotonin reuptake inhibitors] are the first-line pharmacological intervention, with high doses often being required." Limited data suggest that insight-oriented and supportive psychotherapy are "generally ineffective." In addition, patients' attempts to solve their body-image problems through surgical or dermatological procedures are "usually ineffective and may even worsen appearance concerns" (Phillips and Castle, 2002). The Efficacy of CBT and Behavior Therapy As stated earlier, the literature of BDD contains very few controlled studies from which one can extract scientifically-derived conclusions. However, Rosen (1998) described a 1995 controlled experiment using women with BDD, conducted by Rosen, Reiter, and Orosan. Results from the experi5 of 13

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ment included that "three-quarters of treated cases eliminated their disorder, whereas control subjects did not improve." CBT was found to be effective in as little as two months. Rosen concluded that "it is important to recognize that CBT is not uniformly effective, as the disorder is not eliminated in about one-quarter of patients who complete treatment." Wilhelm, Otto, Lohr, and Deckersbach (1998) described CBT-based group treatment of BDD through 12 weekly 90-minute sessions; participants worked in groups of four or five people. The authors did not run a parallel control group, so they could not state any definitive results. However, they stated that "patients in this clinical case series improved significantly across the course of treatment," and they noted that patients' scores on tests measuring BDD and depression showed "linear improvement across the 12 sessions of treatment." In a meta-analysis of 15 randomized clinical trials and case series studies of patients with BDD (Williams, Hadjistavropoulos, and Sharpe, 2005), the authors found that both psychological therapies and pharmacotherapy were effective but that "psychological therapies were found to be more effective than pharmacotherapy" and that "CBT yielded larger effect sizes than pharmacotherapy." However, the meta-analysis did not find statistically significant differences between CBT and BT (behavior therapy) or between BT and pharmacotherapy. Cognitive Model for BDD According to Veale (2002), people with BDD show selective attention to one or more details of their appearance, which magnifies the perceived defects of the associated body part. They internalize this as a distorted body image, which has two important consequences. First, their selective attention is directed at the body image, not their actual body; this accounts for their inability to decrease their dis-

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tress by changing or hiding their physical appearance. Second, they believe that other people see and their physical appearance the same severe defects that they see in their distorted body image. Mirror gazing (one of several appearance-checking behaviors) activates "idealized values about the importance of appearance," with the result that they believe that that their self-worth is determined by their appearance; furthermore, they believe that the only way to feel better about themselves is to mask or correct an appearance defect that, in actuality, exists only in their distorted body image. Wilhelm and Neziroglu (2002) explained the behaviors of people with BDD as follows: Processing perceived appearance flaws leads to negative feelings that cause the sufferer to either avoid situations that trigger the unpleasant feelings or to neutralize them with appearance related rituals or other activities (e.g., reassurance seeking). Avoidance behavior, hiding of the defect[,] and checking, are reinforcing because they provide a short term relief of discomfort. Thus, the rituals and avoidance are the engine that maintains the dysfunctional beliefs in people with BDD, just like in individuals suffering from OCD. Treatment of BDD Using Cognitive and Behavioral Therapies As stated earlier, the literature does not yet contain enough experimental data to lead to either recommendations or guidelines as to the parameters of an effective treatment for BDD. The metaanalysis of Williams, Hadjistavropoulos, and Sharpe (2005) summarizes eight case series and two randomized controlled trials. Of these, nine involved individual treatment and one involved group treatment of BDD; five studies used CBT, four used BT, and one used CT (cognitive therapy). The number of treatments for the nine fixed-length treatments (session length, where given, in parentheses) were: 7, 7 of 13

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8 (2 hours each), 12 (90 minutes), 12, 14 (75 minutes), 20, 24, 24, and 30. Behavioral techniques, when used, were exposure (to uncomfortable situations) and response prevention (to checking behaviors). Cognitive techniques, when used, were cognitive restructuring and unspecified "cognitive therapy." Assessment In any application of CBT, a thorough assessment is necessary for understanding the problem and creating a treatment plan. In the case of using CBT to treat BDD, the assessment should focus on the beliefs and behaviors that maintain the disorder (Veale, 2002). Veale (2002) recommended having the client fill out a form that lists 39 body features and, for each feature, the following information: whether or not the feature is defective; a description of how it is defective; a description of how the client would like this feature to be; the level of distress (on a 0100 scale) that the feature causes; and the frequency (on a 0-4 scale) with which the feature causes distress. This gives the therapist a detailed inventory of the client's perceived defects and the effects of each of these on the client. The therapist should work with the client to determine the client's beliefs about each perceived defect, the values underlying these beliefs, and the personal meaning of each perceived defect. One technique for doing this is asking the client what is most anxiety-provoking about the perceived defect, then working with the client to discover the layers of assumptions underlying the client's anxiety. The cognitive component of treatment centers on testing the validity of such assumptions (Veale, 2002). It is also important in that the therapist determine what behaviors the client engages in as a result of each body feature that the client believes is defective, as well as the client's motivation for doing

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so. This information becomes the raw material from which the therapist constructs behavioral experiments that test the client's beliefs about each perceived defect (Veale, 2002). The therapist and client should work together to determine the following: a description of the problem that focuses on cognitions and behaviors; a formulation of how the problem has developed and how it is maintained; and a concrete description of realistic, achievable goals (Veale, 2002). Clients often benefit from reading "a psycho-educational book about BDD which is written for sufferers," as well as contact with others in a support group for people with similar problems (Veale, 2002). Because mirror-gazing plays an important role in maintaining BDD, Veale (2002) makes eight specific recommendations regarding mirror usage. Among these are: using a variety of close-up and full-body mirrors, not just one "trusted" mirror; limiting the use of mirrors to short periods of time to accomplish specific productive actions (e.g., shaving or applying makeup); focusing on the objective reflection that the mirror provides rather than "an internal impression of how I feel"; and delaying a response to the urge to use mirrors until the urge has diminished. Treatment All that can be offered for the treatment of BDD is an assortment of treatment techniques found in the literature. Most of these techniques have the goal of either decreasing the client's discomfort (by repairing distorted cognitions or by desensitizing the client to problematic situations), or by extinguishing or minimizing maladaptive behaviors. The prevention of checking behaviors is particularly important because they are time-consuming and because they appear to increase rather than decrease the client's anxiety (Wilhelm and Neziroglu, 2002). A key feature of these cognitive and behavioral tech-

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niques is that they can be applied successfully without confronting the client's strongly held belief that the perceived body-part flaws are objectively real. One cognitive technique that is recommended is presenting two alternative hypotheses about the client's life and discussing them during therapy. The first hypothesis is that the client is, in fact, defective or ugly and that the client's current behaviors are appropriate. The alternative is that the client's problems are caused by excessive worry about appearance and by overvaluing appearance so much that it has become the main determinant of the client's self-worth. The discussion of these alternative hypotheses gives the therapist the occasion to describe the cognitive-behavioral model of BDD and to look for evidence that this model explains the client's cognitions and behaviors (Veale, 2002). Veale (2002) recommended the following CBT techniques for treating BDD: "Cognitive restructuring and behavioural experiments to test out assumptions. Reverse role-play for the rigid values. Self-monitoring. Response prevention for compulsive behaviors such as mirror gazing. Behavioural experiments or exposure to social situations without safety behaviour. Habit reversal for impulsive behaviours such as skin-picking." The "safety behaviour" referred to in the fifth technique is a reference to the coping behavior of clients with BDD when they decrease their discomfort in social situations by modifying their behavior in ways that mask or minimize their perceived body flaws (e.g., using hair or makeup to hide a flaw, limiting themselves to situations where the level of light is low). The fifth technique can then be understood as increasing the client's ability to be in social situations without using such safety behaviors. Rosen (1998) briefly described a 10-session protocol for CBT treatment of BDD. This treatment begins with educating the client about physical appearance, body image, and the factors that cause and maintain BDD. It instructs the client to monitor himself and record thoughts and behaviors 10 of 13

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connected to body-image situations. The therapist uses cognitive techniques to control negative body talk, classical exposure therapy to improve the client's ability to view himself in the mirror, cognitive restructuring of the client's maladaptive assumptions about his appearance, exposure therapy for increasingly difficult body-image situations, and response prevention techniques to extinguish or limit excessive behaviors resulting from the client's body-image anxieties. Phillips and Castle (2002) recommended "intensive" use of CBT, including frequent sessions, homework, and both cognitive and ERP (exposure/response prevention) techniques. After treatment is completed, follow-up maintenance sessions are recommended for clients with more severe BDD. If the client is very depressed or suicidal, medication should be used to improve the client's functioning enough for the client to benefit from the additional use of CBT. Conclusions Body dysmorphic disorder occurs when a client's distorted perception of one or more specific body parts leads to behaviors and cognitions that cause the client significant distress or impairment in important areas of the client's life. BDD usually begins in adolescence, where it has serious effects, and can last for decades. CBT is more effective than the best pharmacological intervention (the use of serotonin reuptake inhibitors). Behavioral therapies used include exposure, desensitization, and response prevention techniques. Cognitive therapies used include cognitive restructuring. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text rev.). Washington, DC: Author.

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Hadley, S. J., Greenberg, J., & Hollander, E. (2002). Diagnosis and treatment of body disorder in adolescents. Current Psychiatry Reports, 4, 108-113. Phillips, K. A., & Castle, D. J. (2002). Body dysmorphic disorder. In D. J. Castle & K. A. Phillips (Eds.), Disorders of body image (pp. 101-120). Petersfield, UK: Wrightson Biomedical Publishing Ltd. Rosen, J. C. (1998). Cognitive behavior therapy for body dysmorphic disorder. In V. E. Caballo (Ed.), International handbook of cognitive and in he treatments for psychological disorders (pp. 363391). Oxford, UK: Pergamon. Rossell, S. L., & Castle, D. J. (2006). An update on body dysmorphic disorder. Current Opinion in Psychiatry, 19, 74-78. Slaughter, J. R., & Sun, A. M. (1999). In pursuit of perfection: Primary care physician's guide to body dysmorphic disorder. American Family Physician, 60, 1738-1742. Veale, D. (2002). Cognitive behaviour therapy for body dysmorphic disorder. In D. J. Castle & K. A. Phillips (Eds.), Disorders of body image (pp. 121-138). Petersfield, UK: Wrightson Biomedical Publishing Ltd. Wilhelm, S., & Neziroglu, F. (2002). Cognitive theory of body dysmorphic disorder. In R. O. Frost & G. Steketee (Eds.), Cognitive approaches to its sessions and compulsions: Theory, assessment, and treatment (pp. 203-214). Amsterdam: Pergamon. Wilhelm, S., Otto, M. W., Lohr, B., & Deckersbach, T. (1998). Cognitive behavior group therapy for body dysmorphic disorder: A case series. Behaviour Research and Therapy, 44, 99-111.

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Williams, J., Hadjistavropoulos, T., & Sharpe, D. (2005). A meta-analysis of psychological and pharmacological treatments for body dysmorphic disorder. Behaviour Research and Therapy, 37, 71-75.

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