Body dysmorphic disorder: A cognitive behavioural model and pilot randomised controlled trial

doi:10.1016/0005-7967(96)00025-3

Behaviour Research and Therapy

Volume 34, Issue 9, September 1996, Pages 717-729

https://doi.org/10.1016/0005-7967(96)00025-3 Get rights and content

Abstract

A cognitive behavioural model of body image is presented with specific reference to body dysmorphic disorder (BDD). We make specific hypotheses from the model for testing BDD patients in comparison with: (i) patients with “real” disfigurements who seek cosmetic surgery; (ii) subjects with “real” disfigurements who are emotionally well adjusted; and (iii) healthy controls without any defect. There have been no randomised controlled trials of treatment for BDD and therefore the model has clear implications for the development of cognitive behavioural therapy. This was evaluated in a pilot controlled trial. Nineteen patients were randomly allocated to either cognitive behaviour therapy or a waiting list control group over 12 weeks. There were no significant pre-post differences on any of the measures in the waiting list group. There were significant changes in the treated group on specific measures of BDD and depressed mood. Cognitive behaviour therapy should be further evaluated in a larger controlled trial in comparison with another psychological treatment such as interpersonal therapy and pharmacotherapy.

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Mirror gazing has been linked to poor body image. Cognitive-behavioral models propose that mirror gazing induces self-focused attention. This activates appearance-related imagery, increases body dissatisfaction, and promotes further mirror gazing. However, evidence for these relationships remains scarce. Our study experimentally investigated how self-focused attention impacts overall and facial appearance satisfaction, perceived attractiveness, distress about appearance and disliked features, vividness and emotional quality of appearance-related imagery, and urges to mirror gaze. Baseline body dysmorphic concerns were studied as a moderator.
Singaporean undergraduates (M_age = 21.22, SD_age = 1.62; 35 females, 28 males) were randomly assigned to high or low self-focused attention during a mirror gazing task. Dependent variables were measured with visual analogue scales, and body dysmorphic concerns with the Body Image Disturbance Questionnaire (BIDQ). Analysis of variance and moderation analyses were conducted.
Self-focused attention lowered overall and facial appearance satisfaction. Perceived attractiveness decreased only in individuals with high baseline body dysmorphic concerns. Contrary to predictions, distress, appearance-related imagery, and urges to mirror gaze were unaffected.
This study used a non-clinical sample. The BIDQ has not been psychometrically validated in Singaporean samples.
Self-focused attention during mirror gazing lowers positive body image evaluations. Individuals with higher body dysmorphic concerns are particularly vulnerable to low perceived attractiveness.
Is cognitive behavioral therapy an efficacious treatment for psychological interventions in body dysmorphic disorders? A meta-analysis based on current evidence from randomized controlled trials
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Clinical guidelines and some studies recommend cognitive-behavioral therapy (CBT) as the most effective treatment for body dysmorphic disorder (BDD). However, owing to the lack of randomized controlled trials (RCTs), the research evidence is insufficient. This study aimed to explore the effectiveness of CBT in the treatment of BDD using RCTs. This meta-analysis was registered in PROSPERO (CRD42023410577).
After a literature search and screening, 11 RCTs with 667 patients were included. The ROB 2.0 tool, funnel plots, sensitivity analysis, and meta-regression analysis were used to assess the quality, publication bias, and sources of heterogeneity.
After CBT intervention, the severity of BDD (SMD = −1.73, 95 % CI (confidence interval) = [−2.90; −0.57]), depression symptoms (SMD = −1.72, 95 % CI = [−3.16; −0.28]), and anxiety levels were all reduced in the patients of the experimental group; the remission of BDD (OR = 7.37, 95 % CI = [2.17; 24.98]) and the response of BDD (OR = 8.86, 95 % CI = [4.85; 16.18]) were all increased; incorrect beliefs such as disability and BABS were also reduced; the quality of life was improved. The difference between the groups was statistically significant (p < 0.01). Meta-regression analysis showed that age and sample size were the predictive factors of the effectiveness of CBT.
The heterogeneity of most meta-analyses was high (I² > 75 %).
Although CBT is effective in treating BDD, there is insufficient evidence to suggest that it is the best psychological intervention for BDD. More high-quality evidence is still needed in the future.
Body Dysmorphic Disorder
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Body dysmorphic disorder: A critical appraisal of diagnostic, screening, and assessment tools
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Body dysmorphic disorder (BDD) is a psychiatric condition characterized by profound concern about a minor or imagined defect in the appearance of individuals and increased preoccupation with the imagined/perceived defect. Individuals with BDD often undergo cosmetic intervention for the perceived imperfection but rarely experience improvement in their signs and symptoms after such treatment. It is recommended that aesthetic providers evaluate individuals face-to-face and screen for BDD with approved scales preoperatively to determine the candidate's suitability for the procedure. This contribution focuses on diagnostic and screening tools and measures of disease severity and insight that providers working in nonpsychiatric settings can use. Several screening tools were explicitly developed for BDD; others were designed to evaluate body image/dysmorphic concern. The BDD Questionnaire (BDDQ)–Dermatology Version (BDDQ-DV), BDDQ–Aesthetic Surgery (BDDQ-AS), Cosmetic Procedure Screening Questionnaire (COPS), and Body Dysmorphic Symptom Scale (BDSS) have been developed explicitly for BDD and validated in cosmetic settings. The limitations of screening tools are discussed. Given the increasing use of social media, future revisions of BDD instruments should consider incorporating questions relevant to patients’ behaviors on social media. Current screening tools can adequately test for BDD despite their limitations and a need for updates.
CASE STUDY: A child with body dysmorphic disorder and cognitive-behavioral therapy
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This case study outlines the process of using cognitive-behavioral therapy (CBT), dialectical behavioral therapy (DBT), and exposure response prevention (ERP) to treat a 12-year-old female, “Olivia” diagnosed with body dysmorphic disorder (BDD). Olivia participated in psychotherapy that was individually designed and incorporated core elements from CBT, DBT, and ERP to address perceptual distortions, body image, rumination, avoidance, and ritualistic behaviors. At a certain point, it became evident to involve medication management. In addition, treatment focused on teaching coping skills for distress tolerance, mindfulness, mirror retraining, identifying core fears, and values. The course of treatment began at two times a week, gradually fading to once a week, and eventually biweekly. This case report supports the focus of continued research of pediatric BDD to continue the growth of effective treatment.
Body dysmorphic disorder (BDD) in the orthodontic and orthognathic setting: A systematic review
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General prevalence of Body Dysmorphic Disorder (BDD), a psychiatric disorder in which patients focus on an imagined body defect not visible to others, varies between 0.7 and 2.5%. Up to 86% present with complaints in the area of teeth or face. Patients with BDD pursue an aesthetic rather than functional recovery, making BDD a possible contraindication to treatment. The aim of this systematic review was to review prevalence of BDD within the orthodontic and/or orthognathic population, to describe diagnostic tools for early detection of patients with BDD and to assess the outcome after treatment. A systematic search was conducted up to November 2020 using PubMed, Embase, Web of Science Core Collection and Cochrane Library. Following the screening of 1423 articles, 5 prospective studies were included. Prevalence of BDD within the orthodontic and orthognathic population varied from 5.2% to 13% (average of 6.2%). Literature showed a trend of higher BDD prevalence within younger, female and single patient population, although results are not conclusive. Questionnaires can be useful for preliminary detection of BDD. General anamnesis with questioning medical or psychiatric history, medication and personal expectations remains very important. Red flags could be previous consultations for the same problem or presence of psychiatric comorbidities. Prospective studies are necessary to map satisfaction of these patients and need for re-interventions after treatment.

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Body dysmorphic disorder: A cognitive behavioural model and pilot randomised controlled trial

Abstract

Ethology and Sociobiology

Journal of Experimental Social Psychology

Journal of Behavioral Therapy and Experimental Psychiatry

Behavior Therapy

Behaviour Research and Therapy

Behaviour Research and Therapy

Psychiatry Research

Behaviour Research and Therapy

Behaviour Research and Therapy

Psychosomatics

Behaviour Therapy

Diagnostic and Statistical Manual of Mental Disorders

Factor analysis of symptom subtypes of obsessive compulsive disorder and their relation to personality and tic disorders

Journal of Clinical Psychiatry

Acute exacerbation of body dysmorphic disorder during tryptophan depletion

American Journal of Psychiatry

Solitary psychosis—three cases of monosymptomatic delusion of alimentary tract stench treated with behavioural psychotherapy

British Journal of Psychiatry

Dysmorphophobia in adolescence: A case report

British Journal of Psychiatry

A cognitive model of social phobia

Sex and the symmetrical body

New Scientist

Predictive factors in the reatment of Obsessive Compulsive disorders with fluvoxamine and/or behaviour therapy

Behavioural Psychotherapy

Cyproheptadine dependence associated with an atypical somatoform disorder

Canadian Journal of Psychiatry

Does rational roleplay enhance the outcome of exposure therapy in dysmorphophobia? A case study

British Journal of Psychiatry

Increased cardiac awareness in panic disorder

Journal of Abnormal Psychology

Failures in Behavior Therapy

Dysmorphophobia: Clinical features and outcome with behaviour therapy

European Psychiatry

The treatment of obsessive compulsive disorder: approaches using behavioural psychotherapy alone or in combination with other treatments

Journal of Serotonin Research

The symptomatology of abnormal appearance: an anecdotal survey

British Journal of Plastic Surgery

The benefits and hazards of cosmetic surgery

British Journal of Hospital Medicine

Changes in psychometric test results following cosmetic nasal operations

British Journal of Psychiatry

Obsessive-compulsive spectrum disorders: An overview

Psychiatric Annals

Fluvoxamine treatment of body dysmorphic disorder

Journal of Clinical Psychopharmacology

Serotonergic and noradrenergic sensitivity in obsessive-compulsive disorder: Behavioral findings

Treatment of body-dysmorphic disorder with serotonin reuptake blockers

American Journal of Psychiatry

A study of the perception of body-image in patients requesting cosmetic rhinoplasty