Modular cognitive-behavioral therapy for body dysmorphic disorder

This study pilot tested a newly developed modular cognitive–behavioral therapy (CBT) treatment manual for body dysmorphic disorder (BDD). We tested feasibility, acceptability, and treatment outcome in a sample of 12 adults with primary BDD. Treatment was delivered in weekly individual sessions over 18 or 22 weeks. Standardized clinician ratings and self-report measures were used to assess BDD and related symptoms pre- and posttreatment and at 3- and 6-month follow-ups. At posttreatment, BDD and related symptoms (e.g., mood) were significantly improved. Treatment gains were maintained at follow-up. A relatively low drop-out rate, high patient satisfaction ratings, and patient feedback indicated that the treatment was highly acceptable to patients. To our knowledge, this represents the first test of a broadly applicable, individual psychosocial treatment for BDD.     

Perceived teasing experiences in body dysmorphic disorder

Individuals with body dysmorphic disorder (BDD) are excessively concerned about imagined or slight defects in their appearance (e.g., asymmetrical facial features). Cognitive-behavioral models of BDD propose that several factors, including dysfunctional appearance-related beliefs and life experiences, such as teasing, contribute to the avoidance behaviors or rituals (e.g., mirror checking, grooming) characteristic of BDD. Previous research has demonstrated an association between perceived teasing and body dissatisfaction. In the current study, we examined whether individuals with BDD (n = 16) report to have been teased more often than do mentally healthy controls (n = 17). The group comprising individuals with BDD reported more appearance- and competency-related teasing than did control participants. This study provides preliminary evidence for the association between perceived teasing and BDD.     

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.     

Emotion recognition in body dysmorphic disorder: Application of the Reading the Mind in the Eyes Task

Body dysmorphic disorder (BDD) is characterized by perceived appearance-related defects, often tied to aspects of the face or head (e.g., acne). Deficits in decoding emotional expressions have been examined in several psychological disorders including BDD. Previous research indicates that BDD is associated with impaired facial emotion recognition, particularly in situations that involve the BDD sufferer him/herself. The purpose of this study was to further evaluate the ability to read other people's emotions among 31 individuals with BDD, and 31 mentally healthy controls. We applied the Reading the Mind in the Eyes task, in which participants are presented with a series of pairs of eyes, one at a time, and are asked to identify the emotion that describes the stimulus best. The groups did not differ with respect to decoding other people's emotions by looking into their eyes. Findings are discussed in light of previous research examining emotion recognition in BDD.     

The relationship between body dysmorphic disorder behaviors and the acquired capability for suicide

In a sample of 200 individuals diagnosed with body dysmorphic disorder (BDD), we utilized the interpersonal-psychological theory for suicide as a framework to examine BDD behaviors that might be associated with suicide risk, insofar as they might increase the acquired capability for suicide. We predicted that physically painful BDD behaviors (e.g., cosmetic surgery, restrictive eating) would be associated with suicide attempts but not suicide-related ideation because these behaviors increase capability for, but not thoughts about, suicide. Our hypothesis was partially confirmed, as BDD-related restrictive food intake was associated with suicide attempts (but not suicide-related ideation) even after controlling for numerous covariates.     

Effectiveness of Multimodal Treatment for Young People With Body Dysmorphic Disorder in Two Specialist Clinics

Body dysmorphic disorder (BDD) typically originates in adolescence and is associated with considerable adversity. Evidence-based treatments exist but research on clinical outcomes in naturalistic settings is extremely scarce. We evaluated the short- and long-term outcomes of a large cohort of adolescents with BDD receiving specialist multimodal treatment and examined predictors of symptom improvement. We followed 140 young people (age range 10–18) with a diagnosis of BDD treated at two national and specialist outpatient clinics in Stockholm, Sweden (n = 96) and London, England (n = 44), between January 2015 and April 2021. Participants received multimodal treatment consisting of cognitive behavior therapy and, in 72% of cases, medication (primarily selective serotonin reuptake inhibitors). Data were collected at baseline, posttreatment, and 3, 6, and 12 months after treatment. The primary outcome measure was the clinician-rated Yale-Brown Obsessive-Compulsive Scale Modified for BDD, Adolescent version (BDD-YBOCS-A). Secondary outcomes included self-reported measures of BDD symptoms, depressive symptoms, and global functioning. Mixed-effects regression models showed that BDD-YBOCS-A scores decreased significantly from baseline to posttreatment (coefficient [95% confidence interval] = -16.33 [-17.90 to -14.76], p<0.001; within-group effect size (Cohen’s d) = 2.08 (95% confidence interval, 1.81 to 2.35). At the end of the treatment, 79% of the participants were classified as responders and 59% as full or partial remitters. BDD symptoms continued to improve throughout the follow-up. Improvement was also seen on all secondary outcome measures. Linear regression models identified baseline BDD symptom severity as a predictor of treatment outcome at posttreatment, but no consistent predictors were found at the 12-month follow-up. To conclude, multimodal treatment for adolescent BDD is effective in both the short- and long-term when provided flexibly within a specialist setting. Considering the high personal and societal costs of BDD, specialist care should be made more widely available.     

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.     

Assessing the Prevalence of Body Dysmorphic Disorder in an Ethnically Diverse Group of Adolescents

We investigated the prevalence of Body Dysmorphic Disorder (BDD) in an ethnically diverse sample of adolescents (N = 566) using the Body Image Rating Scale, a brief self-report measure for assessing body dissatisfaction. Results showed that adolescent girls were more dissatisfied with their bodies than adolescent boys, and that African-Americans of both genders were less dissatisfied with their bodies than Caucasians, Asians, and Hispanics. The interaction between gender and ethnicity was not significant. We found an overall prevalence for BDD of 2.2%. Although these are the first data on the prevalence of BDD in an ethnically diverse group of adolescents, they are consistent with the other study on the prevalence of BDD in a predominantly Caucasian group of college students.     

Reality monitoring in patients with body dysmorphic disorder

Patients with body dysmorphic disorder (BDD) typically have very poor insight into their disorder. Their conviction in their ugliness is often of delusional intensity. Reality monitoring is the ability to distinguish in memory between things that one has imagined and things that one has perceived. Deficits in reality monitoring have been associated with the development of other delusional beliefs. Therefore, in the present study we investigated whether individuals with BDD (n = 20) demonstrate impairments in reality monitoring relative to individuals with obsessive-compulsive disorder (OCD; n = 20) and healthy controls (n = 20). This hypothesized impairment might predispose people with BDD to confuse memories of how they imagine themselves to appear (i.e., ugly) with memories of how they actually appear (i.e., normal). All participants completed a memory task assessing reality-monitoring ability for verbal stimuli. The BDD patients did not exhibit a reality-monitoring deficit despite elevated levels of focal delusionality. The results suggest that impairments in reality monitoring do not contribute to the development or maintenance of appearance-related beliefs in BDD.     

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.     

Body dysmorphic disorder and appearance enhancing medical treatments

This article reviews the literature on body dysmorphic disorder (BDD) in persons who seek appearance enhancing medical treatments such as cosmetic surgery and dermatological treatment. We begin with a discussion of the growing popularity of cosmetic surgical and minimally invasive treatments. The literature investigating the psychological characteristics is briefly highlighted. Studies investigating the rate of BDD among persons who seek appearance enhancing treatments are detailed and, collectively, suggest that approximately 5–15% of individuals who seek these treatments suffer from BDD. Retrospective reports suggest that persons with BDD rarely experience improvement in their symptoms following these treatments, leading some to suggest that BDD is a contraindication to cosmetic surgery and other treatments. The clinical management of patients with BDD who present for these treatments is briefly described and directions for future research are provided.     

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.     

A Multimethod Analysis of Incompleteness and Visual “Not Just Right” Experiences in Body Dysmorphic Disorder

Individuals with body dysmorphic disorder (BDD) often report engaging in repetitive behaviors aimed at reducing feelings of imperfection anchored to their appearance. “Not just right” experiences (NJREs) and incompleteness (INC) are constructs related to perfectionism that have traditionally been studied in obsessive-compulsive disorder, though recent research has also linked these phenomena to BDD. We sought to replicate and extend this research via two studies. Study 1 examined BDD symptoms, INC, as well as harm avoidance (HA) in an unselected sample (N = 179); moderate associations were observed between symptoms and both INC and HA. Participants also completed a novel visual NJRE task in which they were shown appearance-related and non-appearance-related images meant to evoke an NJRE response (i.e., discomfort and urge to “fix” stimuli). BDD symptoms predicted reactivity to appearance-related NJRE stimuli above negative affect. Study 2 compared INC, HA, and task reactivity in a BDD sample (N = 50) to nonpsychiatric controls (N = 44). The BDD group evidenced greater INC, HA, and reactivity to both appearance and nonappearance NJRE stimuli, relative to controls; however, group differences did not remain after controlling for age and negative affect. These studies broadly corroborate previous research highlighting NJREs and INC as potential vulnerability factors relevant to BDD, though these phenomena may not be specific to BDD symptoms.     

The pathophysiology of body dysmorphic disorder

Body dysmorphic disorder (BDD) is an often severe and disabling condition, affecting up to 2% of the population. Despite its prevalence and clinical significance, very little is known about the pathophysiology of BDD. However, clues to its possible neurobiological substrates and abnormalities in information processing are starting to emerge. This article reviews findings from genetic, brain lesion, neuroimaging, neuropsychological, and psychopharmacological studies that have allowed us to develop a tentative model of the functional neuroanatomy of BDD. There is likely a complex interplay of dysfunctions in several brain networks underlying the pathophysiology of BDD. A combination of dysfunctions in frontal-subcortical circuits, temporal, parietal, and limbic structures, and possibly involving hemispheric imbalances in information processing, may produce both the characteristic symptoms and neurocognitive deficits seen in BDD. An improved understanding of the pathophysiology of BDD will be crucial to guide the development of better treatments.     

An Evaluation of the Body Dysmorphic Disorder Symptom Scale as a Measure of Treatment Response and Remission in Psychotherapy and Medication Trials

The Body Dysmorphic Disorder Symptom Scale (BDD-SS) is a self-report tool that captures an array of representative behavioral and cognitive symptoms commonly displayed by individuals with BDD. The BDD-SS is regularly used among experts in the field, though its utility as a measure of treatment response has not yet been formally evaluated. Results from two clinical trials of BDD treatment were pooled from an archived database to create a sample of 220 BDD participants who received either psychosocial or medication-based interventions for BDD. We used baseline BDD-SS scores to describe psychometric properties, baseline correlations with other scales to examine the content validity of the BDD-SS, and longitudinal symptom data to evaluate capacity to detect clinically relevant change. Results indicated that the BDD-SS has good psychometric properties and is able to detect symptom change over time, although it showed lower rates of reliable change with treatment relative to the gold standard rater-administered Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS). The BDD-SS offers meaningful information about treatment response in a self-report format and may be particularly useful to employ in clinical practice settings as a means of gathering symptom and treatment response data via self-report when rater-administered interviews are not feasible, although it may underestimate the extent of improvement with treatment.     

Can the Mind Command the Body?

People naturally intuit that an agent's ethereal thoughts can cause its body to move. Per intuitive physics; however, one body can only interact with another. Are people, then, covertly puzzled by the capacity of thoughts to command the body? Experiment 1 first confirms that thoughts (e.g., thinking about a cup) are indeed perceived as ethereal—as less detectible in the body (brain), and more likely to exist in the afterlife relative to matched percepts (e.g., seeing a cup). Experiments 2–5 show that thoughts are considered less likely to cause behavior than percepts (e.g., thinking of a cup vs. seeing one). Furthermore, mind–body causation is more remarkable when its bodily consequences are salient (e.g., moving an arm vs. brain activation). Finally, epistemic causes are remarkable only when they are ascribed to mental- (e.g., “thinking”) but not to physical states (“activation”). Together, these results suggest that mind–body interactions elicit a latent dualist dissonance.     

Children's and Adults' Acquisition of Spatial Information: Actual and Simulated Environmental Experience

Undergraduate students were presented with word pairs (e.g., egg-yolk) and were timed as they decided whether one word named part of the thing named by the other word. In Experiment 1, “no” responses to nonpart pairs (e.g., fish-flaps) were slowed by the similarity of the stimulus part (flaps) to a part that the stimulus object did possess (fins). This suggested that decisions were made by retrieving parts of the stimulus object from memory and comparing them to the stimulus part. Whereas the parts used as stimuli in Experiment 1 were nonspecific, belonging to several different types of object (e.g., wheel), those selected for Experiment 2 were specific to a single type of object (e.g., thumb). In Experiment 2, “no” responses to nonpart pairs (e.g., foot-thumb) were slowed by similarity of the stimulus object (foot) to an object that the stimulus part (thumb) belonged to (hand). This suggested that decisions were made by retrieving the object to which the stimulus part belonged and comparing it to the stimulus object. The results support a hybrid model of part-whole decisions that includes directed retrieval of relational knowledge from memory and a comparison process.     

体像障碍的认知机制及治疗

体像障碍是一种对想象的或轻微外表缺陷的先占观念, 这种先占观念给个体带来极大的痛苦。其负性的自我认知框架, 影响个体对信息的选择、组织及评估。因此结合心理实验范式和神经生理综合分析体像障碍的认知过程, 对深化体像障碍认知机制和优化其认知行为治疗具有重要意义。     

The phenomenology of self-reported body dysmorphic disorder by proxy

Body dysmorphic disorder by proxy (BDDBP), a preoccupation with a perceived defect in another person's appearance may represent a variant of BDD. However, BDDBP has received little empirical attention. We present here the phenomenology of 11 individuals with self-reported BDDBP. Participants completed an internet-based survey that assessed symptoms, psychosocial impact, and treatment history. Participants (8 females, 3 males) reported preoccupation with a wide array of individuals (e.g., spouse, stranger). Body parts of concern most commonly involved the face and head. Most participants spent several (e.g., 3–8) hours per day preoccupied by perceived defects in the person of concern (POC). All participants engaged in rituals to try to alleviate distress or improve the POC's appearance. Most avoided social/occupational activities, including contact with the POC. The impact of BDDBP was profound, particularly on relationships. Findings may help elucidate diagnostic criteria, course, and treatment.