Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder: A Pilot Study

Body dysmorphic disorder (BDD) is a relatively common and severe disorder that typically onsets in adolescence, but often goes unrecognized. Despite BDD’s severity and early onset, treatment outcome research on adolescent BDD is scarce. Cognitive-behavioral therapy is the gold-standard psychosocial treatment for BDD in adults and has shown promise in adolescents. The current study examined the development and testing of a new CBT for adolescents with BDD. We tested feasibility, acceptability, and treatment outcome in a sample of 13 adolescents (mean age 15.23 years, range: 13–17) with primary BDD. Treatment was delivered in 12–22 weekly individual sessions. Standardized clinician ratings and self-report measures were used to assess BDD and related symptoms pre- and posttreatment and at 3- and 6-months follow-up. At posttreatment, BDD and related symptoms (e.g., insight, mood) were significantly improved. Scores on the Yale–Brown Obsessive Compulsive Scale for BDD indicated a 50% (intent-to-treat) and 68% (completer) improvement in BDD symptoms. Seventy-five percent of adolescents who started treatment and 100% of completers were considered treatment responders. Treatment gains were maintained at follow-up. High patient satisfaction ratings and patient feedback indicated that treatment was acceptable. This represents the largest study of a psychosocial treatment for adolescent BDD.     

Cognitive-Behavioral Therapy for Body Dysmorphic Disorder by Proxy

Body dysmorphic disorder (BDD) is a distressing or impairing preoccupation with a perceived defect in physical appearance. BDD by proxy (BDDBP) is a significant but understudied variant of BDD in which the primary preoccupation involves perceived imperfections of another person. Like BDD, individuals with BDDBP engage in time-consuming rituals to “fix” the other person’s appearance or alleviate distress. Avoidance is common and the impact of BDDBP on social functioning is profound. Cognitive-behavioral therapy (CBT) is the best-studied and most promising psychological treatment for BDD, but no studies have examined its generalizability to the BDDBP variant. We tested feasibility, acceptability, and treatment outcome of CBT modified for BDDBP in a sample of 6 adults with primary BDDBP. Treatment was delivered in weekly individual sessions over 12–20 weeks. Mean symptom severity (BDDBP-YBOCS) dropped from the moderately severe range at pretreatment to the subclinical range at posttreatment, t(6) = 10.7, p < .001, d = 3.3. One hundred percent of treatment completers were responders (≥ 30% reduction in BDDBP-YBOCS). Insight also improved. Treatment gains were maintained at 3-month follow-up. To our knowledge, this represents the first treatment study for BDDBP.     

Predictors of Response to Cognitive-Behavioral Therapy for Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a common and distressing or impairing preoccupation with a perceived defect in physical appearance. Individuals with BDD engage in time-consuming rituals to check, hide, or “fix” their appearance or alleviate distress. BDD is associated with substantial psychosocial impairment and high rates of depression, hospitalization, and suicidality. Cognitive-behavioral therapy (CBT) is the treatment of choice for BDD, but not everyone benefits. We examined predictors of CBT-related improvement, an important topic that has received very limited investigation. Treatment was delivered in weekly individual sessions over 18–22 weeks. Results indicated that greater motivation/readiness to change (University of Rhode Island Change Assessment Questionnaire), greater treatment expectancy (Treatment Credibility/Expectancy Questionnaire), and better baseline BDD-related insight (Brown Assessment of Beliefs Scale) significantly predicted better CBT response at posttreatment. Baseline BDD symptom severity and depression did not predict outcome, suggesting that even patients with more severe BDD and depressive symptoms can benefit from CBT for BDD. Efforts should be aimed at enhancing readiness to change and confidence in the treatment at treatment onset as well as addressing the poor insight that often characterizes BDD.     

Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial

There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). CBT-BDD utilizes core elements relevant to all BDD patients (e.g., exposure, response prevention, perceptual retraining) and optional modules to address specific symptoms (e.g., surgery seeking).     

Development and Pilot Testing of a Cognitive-Behavioral Therapy Digital Service for Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) has a severe presentation and chronic course when untreated. Although effective BDD treatments exist, most individuals do not have access to them. We therefore developed and pilot tested the first smartphone-delivered individual cognitive-behavioral therapy (CBT) treatment for adults with BDD. The digital service was developed via user-centered design, integrating input from engineering, design, and psychology experts, plus BDD patient consultants. We conducted a 12-week open pilot trial (N = 10) to describe preliminary results for feasibility, acceptability, and treatment outcome. Attrition rates (0%) and feedback on usability and satisfaction indicated that smartphone-based CBT for BDD may be feasible, acceptable, and satisfactory. Initial results suggest that smartphone-based CBT for BDD may hold promise for improving BDD symptom severity, BDD-related insight, functional impairment, and quality of life, as scores from baseline to posttreatment improved with large-to-very large effects; depression improved with a medium effect. Ninety percent of participants were responders at posttreatment and 3-month follow-up. Smartphone-based CBT for BDD may have strong potential as a standardized, low cost, and accessible treatment for this debilitating illness. A test of efficacy is merited as a next step, using a well-powered, randomized control trial design.     

Sudden Gains in Internet-Based Cognitive Behavior Therapy for Body Dysmorphic Disorder

Sudden gains have been associated with better short- and long-term treatment outcomes in a number of psychiatric disorders. However, no studies to date have evaluated sudden gains in body dysmorphic disorder (BDD). We used data from a previous randomized controlled trial evaluating the efficacy of an Internet-based cognitive-behavior treatment (CBT) for BDD. The sample consisted of 47 adults diagnosed with BDD. We compared the treatment outcomes of sudden gainers vs. gradual gainers (i.e., treatment responders with no sudden gains) and non-sudden gainers (i.e., gradual gainers plus nonresponders) at posttreatment and 3, 12, and 24 months after the end of the treatment. Twelve (25.5%) participants experienced a sudden gain. Compared to non-sudden gainers and to gradual gainers, sudden gainers showed significantly larger improvements on the Yale-Brown Obsessive-Compulsive Scale modified for BDD at posttreatment (g = 1.23 and g = .91, respectively), and at 3-month (g = 1.23 and g = 1.00, respectively), 12-month (g = 1.12 and g = .91, respectively), and 24-month follow-up (g = 1.11 and g = .97, respectively). This translated into higher rates of treatment responders and remitters in the sudden gainers across all time points. The occurrence of sudden gains in Internet-based CBT for BDD is associated with favorable short- and long-term treatment outcomes. This suggests that a sudden improvement during the treatment could be a marker of good prognosis, while non-sudden—including gradual—gainers are more likely to need continued support or booster sessions. Early identification of patients who are not progressing as expected and subsequent tailoring of the delivered intervention has the potential to improve treatment outcomes in this group.     

Efficacy of Cognitive Therapy for Body Dysmorphic Disorder: A Randomized Controlled Pilot Trial

Dysfunctional cognitive processes and maladaptive interpersonal patterns have been postulated to maintain body dysmorphic disorder (BDD). The present trial evaluated CT for BDD (CT-BDD), which includes modules targeting maladaptive cognitive processing in BDD, as well as elements of schema therapy related to interpersonal problems. We investigated whether (a) CT-BDD is effective, as compared with a wait-list (WL) group at Week 12; (b) outcome of CT-BDD is maintained at posttreatment and 3- and 6-months follow-up; and (c) whether changes in shame and insight mediate changes in BDD symptom severity. Forty adults with BDD were randomized to 36 weeks immediate CT-BDD (n = 21), or to 12-week WL (n = 19). At Week 12, immediate CT-BDD was significantly superior to WL in clinician-rated BDD symptom severity, insight, self-reported BDD symptoms, shame, depression, general symptomatology, and life satisfaction. Changes in outcomes were associated with moderate to large effect sizes at Week 12. Reductions in shame and increase in insight separately mediated changes in BDD symptom severity during treatment at Week 12. From baseline to posttreatment, significant improvements occurred within CT-BDD in clinician-rated symptom severity, insight, depression, global functioning, self-reported BDD symptoms, shame, depression, general symptomatology, and life satisfaction. At posttreatment, improvements were associated with large effect sizes and were maintained at 3- and 6-month follow-up. Preliminary results support the efficacy of CT-BDD. Addressing interpersonal problems in addition to cognitive dysfunctions may increase the benefit of CBT for BDD patients.     

Feminist Cognitive-Behavioral Therapy for Negative Body Image

Negative body image in women is evidence of internalized cultural messages about obtaining an unrealistic and changing body image ideal. Feminist therapy for negative body image balances an emphasis on socio-cultural and intrapsychic issues, while cognitive-behavioral therapy addresses specific thought patterns and dysfunctional behaviors. This paper reviews the literature on these approaches and gives specific suggestions for developing an integrated model. Ideas for setting the stage for therapy and using psychoeducational material are presented. Discussion also includes feminist cognitive restructuring, including normalizing and relabelling beliefs and developing counterarguments and adaptive restatements. Behavioral interventions include confronting avoidance behaviors and body image distortion, and including kinesthetic experiences and nurturing behaviors.     

Early Change Trajectories in Cognitive-Behavioral Therapy for Binge-Eating Disorder

Rapid response is considered the most well-established outcome predictor across treatments of binge-eating disorder (BED), including cognitive-behavioral therapy (CBT). This study sought to identify latent trajectories of early change in CBT and compare them to common rapid response classifications. In a multicenter randomized trial, 86 adults with BED (DSM-IV) or subsyndromal BED provided weekly self-reports of binge eating over the first 4 weeks of CBT, which were analyzed to predict binge eating, depression, and body mass index at posttreatment, 6-, and 18-month follow-up. Using latent growth mixture modeling, three patterns of early change—including moderate and low decreasing—as well as low stable binge eating were identified, which significantly predicted binge-eating remission at 6-month follow-up. Other classifications of rapid response based on Receiver Operating Characteristics curve analyses or on the literature (≥ 10% reduction in binge eating at week 1, ≥ 70% reduction in binge eating at week 4) only predicted posttreatment remission or overall depression, respectively. Latent change trajectories, but not other rapid response classifications, predicted binge-eating frequency over time. A fine-grained analysis of change over the first 4 weeks of CBT for BED revealed different trajectories of early change in binge eating that led to an improved prediction of binge-eating outcome, compared to that of common rapid response classifications. Thorough monitoring of early change trajectories during treatment may have clinical utility.     

A meta-analysis of psychological and pharmacological treatments for Body Dysmorphic Disorder

Although psychological and pharmacological treatment approaches for Body Dysmorphic Disorder have been evaluated, the relative effectiveness of these two types of interventions has not been examined. We conducted a meta-analysis of randomized clinical trials and case series studies involving psychological (i.e., behavioural, cognitive-behavioural, cognitive) or medication therapies. Our findings support the effectiveness of both types of therapy, but suggest that cognitive-behavioural treatment may be the most useful. These findings require cross-validation through large-scale clinical trials.     

Social-evaluative versus self-evaluative appearance concerns in Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD) is characterised by significant preoccupation and distress relating to an imagined or slight defect in appearance. Individuals with BDD frequently report marked concerns relating to perceived negative evaluation of their appearance by others, but research specifically investigating such concerns remains limited. This study investigated the extent and nature of appearance-related social-evaluative and self-evaluative concerns in individuals with BDD and healthy controls. BDD participants, in comparison to controls, reported high levels of importance and anxiety associated with perceptions of others' views of their appearance, in addition to their own view. No differences were observed in the level of importance and anxiety associated with their self-view in comparison to others' views. These findings support existing evidence indicating that appearance-related social-evaluative concerns are a central feature of BDD. Cognitive-behavioural treatment implications are discussed.     

躯体变形障碍与美容整形术前心理评估

躯体变形障碍是一种并不罕见的精神障碍,其临床表现的特殊性使大多数患者以普通求术者的身份出现在美容整形科医生面前。然而,关容整形手术非但不能解决患者的心理问题,更可能引发复杂的医疗纠纷。基于躯体变形障碍在美容整形科呈高发生率的特点,文章对美容整形术前心理评估的必要性和现状进行分析,并列举了有效的评估工具以提高心理评估的准确性。     

Clinical Application of a Behavioral Model for the Treatment of Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is characterized by an obsessive concern over a perceived flaw in bodily appearance. If a minor flaw does exist, the patient displays unwarranted distress. This preoccupation typically leads to compulsive behaviors, such as mirror checking or mirror avoiding, camouflaging, and seeking reassurance from others regarding one’s appearance or the perceived “flaw.” Although some theorists have outlined important maintaining mechanisms of the disorder, a full model of the etiology and maintenance of this disorder has only recently been articulated in the literature (Neziroglu, Roberts, & Yaryura-Tobias, (2004). A behavioral model for body dysmorphic disorder. Psychiatric Annals, 34, 915–920.). The aim of the present article is to review this model and demonstrate its application to the successful treatment of BDD via a case presentation.     

Therapist Awareness of Client Resistance in Cognitive-Behavioral Therapy for Generalized Anxiety Disorder

Clients' resistance relates negatively to their retention and outcomes in psychotherapy; thus, it has been increasingly identified as a key process marker in both research and practice. This study compared therapists' postsession ratings of resistance with those of trained observers in the context of 40 therapist–client dyads receiving 15 sessions of cognitive-behavioral therapy for generalized anxiety disorder. Therapist and observer ratings were then examined as correlates of proximal (therapeutic alliance quality and homework compliance) and distal (posttreatment worry severity) outcomes. Although there was reasonable concordance between rater perspectives, observer ratings were highly and consistently related to both proximal and distal outcomes, while therapist ratings were not. These findings underscore the need to enhance therapists' proficiency in identifying important and often covert in-session clinical phenomena such as the cues reflecting resistance and noncollaboration.     

Mindfulness-Based Cognitive-Behavioral Conjoint Therapy for Posttraumatic Stress Disorder: A Case Study

With as many as 1.9 million men and women deployed as part of the wars in Iraq and Afghanistan, increased recognition is being placed on the effect of returning Veterans’ combat experiences on their adjustment and mental health, particularly those with symptoms of posttraumatic stress disorder (PTSD) and associated effects on families and relationships. Cognitive-behavioral conjoint therapy (CBCT) for PTSD is a manualized intervention with demonstrated efficacy in clinical trials with Veterans who have experienced trauma and their intimate partners. This case study involves the successful application of Mindfulness-based CBCT for PTSD to treat an operation Iraqi freedom male Veteran and his wife referred for PTSD and relationship dissatisfaction. In the current study, mindfulness interventions were integrated into the existing CBCT for PTSD protocol and treatment duration was shortened by including a weekend group retreat for couples. Baseline and post-treatment data from self- and partner-report measures demonstrates symptom reduction in posttraumatic stress symptoms as well as an increase in relationship satisfaction. The advantages of incorporating mindfulness strategies into this treatment protocol and recommendations for future work are discussed.     

Social Anxiety and Its Relationship to Functional Impairment in Body Dysmorphic Disorder

Social anxiety appears to be a prominent characteristic of body dysmorphic disorder (BDD). However, few previous studies have examined social anxiety and its facets (i.e., physiological arousal, fear and avoidance of social situations) and their relationship to psychosocial functioning in BDD. The present study aimed to fill these gaps by examining (a) social anxiety and its facets in BDD, and b) cross-sectional and prospective relationships between social anxiety symptoms and functional impairment in BDD. Individuals with DSM-IV BDD without comorbid social phobia (N = 108) completed measures of social anxiety and psychosocial functioning at study intake (T1). Psychosocial functioning was also assessed at a 12-month follow-up interview (T2). Severity of social anxiety (i.e., due to BDD or any other source) was rated with the Social Phobia Inventory (SPIN). In addition, participants were interviewed with the Duke Brief Social Phobia Scale (BSPS) to assess social anxiety independent of BDD. At T1, participants endorsed high levels of social anxiety on the SPIN and subclinical levels of social anxiety on the BSPS. Greater social anxiety was associated with poorer psychosocial functioning in cross-sectional and prospective analyses, particularly fear and avoidance of social situations. These results suggest that certain aspects of social anxiety, especially social fear and avoidance, may be significant contributing factors to functional impairment in individuals with BDD.     

Case Conceptualization and Treatment of Comorbid Body Dysmorphic Disorder and Bulimia Nervosa

Body dysmorphic disorder (BDD) and eating disorders often co-occur and share some clinical features. In addition, the co-occurrence of BDD and an eating disorder may be associated with greater impairment in functioning. Furthermore, clinical impressions suggest that this comorbidity may be more treatment resistant than either disorder alone. The current article discusses the treatment of a 48-year-old female diagnosed with BDD and comorbid bulimia. We attempted to address these co-occurring disorders in a strategic, formulation-based manner using a variety of cognitive-behavioral strategies such as cognitive restructuring, rational disputation, exposure with response prevention, and mirror retraining. Despite the complexity of this case, results suggest that comorbid BDD and bulimia nervosa can be effectively managed with cognitive behavioral therapy.     

Exposure-Based Cognitive-Behavioral Therapy for Disruptive Mood Dysregulation Disorder: An Evidence-Based Case Study

Severe, chronic irritability is one of the most frequently reported problems in youth referred for psychiatric care. Irritability predicts adult depressive and anxiety disorders, and long-term impairment. Reflecting this pressing public health need, severe, chronic, and impairing irritability is now codified by the DSM-5 diagnosis of disruptive mood dysregulation disorder (DMDD). Since DMDD has only recently been added as its own nosological class, efficacious treatments that specifically target severe irritability as it presents in DMDD are still being developed. In a recent pilot study, we described the general concept of exposure-based cognitive-behavioral therapy (CBT) for irritability. This mechanism-driven treatment is based on our pathophysiological model of irritability that postulates two underlying mechanisms, which potentiate each other: (1) heightened reactivity to frustrative nonreward, and (2) aberrant approach responses to threat. In this case report, we describe and illustrate the specific therapeutic techniques used to address severe irritability in an 11-year-old boy with a primary diagnosis of DMDD. Specific techniques within this CBT include motivational interviewing to build commitment and target oppositionality; creation of an anger hierarchy; in-session controlled, gradual exposure; and parent training focusing on contingency management to counteract the instrumental learning deficits in irritable youth. Parents learn to tolerate their own emotional responses to their youth’s irritability (e.g., parents engage in their own exposure) and increase their adaptive contingencies for their youth’s behavior (e.g., withdraw attention during unwanted behavior, praise desirable behavior). Future directions in the context of this CBT, such as leveraging technology, computational modeling, and pathophysiological targets, are discussed.