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Cognitive Behavioural Therapy for Body Dysmorphic Disorder

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Cognitive Behavioural Therapy for Body Dysmorphic Disorder

A Quick Refresher

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What is Body Dysmorphic Disorder?
Body dysmorphic disorder is a condition that involves an extreme preoccupation with one’s own perceived defects in physical appearance. Often, these "flaws" are minor and go unnoticed by others. Nevertheless, to reduce the distress associated with the features, individuals may engage in the enactment of repetitive behaviours, including:
  • Mirror checking: Individuals consistently check their reflection and fixate upon certain parts of their appearance
  • Excessive grooming: To mask their insecurities, individuals may wear makeup to the gym, or thick foundation to the corner shop
  • Skin picking: Individuals may pull at their lips, fingertips, cheeks, or loose skin
  • Reassurance seeking: Individuals may feel the need to have their self-worth affirmed and reaffirmed by external parties such as their friends or significant others
  • Physical comparisons: Individuals may find themselves comparing their appearance to people in real life and social media models
Individuals experiencing this condition may also engage in avoidance, manifesting as an extreme reluctance to partake in social situations wherein their perceived inadequacy may be noticed by others. Other safety behaviours employed include camouflaging, in which they attempt to hide or conceal their perceived imperfections. Individuals with body dysmorphic disorder may elect to hide behind makeup, attire or accessories such as hats and/or sunglasses to mask their insecurities. Others may elect to undergo cosmetic procedures in an attempt to permanently “fix” or “correct” their perceived blemishes. Those with body dysmorphic disorder usually involuntarily fixate upon several parts of their bodies. This area of fixation may change over time. The following features are commonly scrutinized:
  • Parts of the face
  • Hair
  • Skin
  • Breast size
  • Muscle size
  • Genitalia
Collectively, the symptoms of the condition are detrimental to one’s day-to-day life and may lead to considerable distress and impairment across important life domains, interfering with functioning (social, occupational or otherwise). Normal functioning is typically only maintained through conscious exertion and additional effort. Importantly, the symptoms of body dysmorphic disorder are not better explained by another mental health condition, medication or substance on the central nervous system. Further, symptoms are not better attributable to the the effects of withdrawal.
Symptoms of Body Dysmorphic Disorder
For a comprehensive list of body dysmorphic disorder symptomatology, we recommend you visit the ICD-11 webpage.

Theoretical Basis

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Cognitive Behavioural Theory of Body Dysmorphic Disorder
In the following section, we describe the cognitive behavioural model of body dysmorphic disorder proposed by Fang and Wilhelm (2015). The model rests on the premise that everyone occasionally endures negative thoughts regarding their appearance. The difference between these individuals, and individuals with body dysmorphic disorder, however, lies in the way that these thoughts are processed and responded to. Those with body dysmorphic disorder place significant importance on appearance and consequently attach much value and weight to negative thoughts regarding their self-image. These individuals process these negative perceptions in a biased manner, allocating much of their attention to certain parts of their appearance as opposed to processing their physique holistically. Maladaptive thoughts and beliefs may include:
  • My hair looks terrible therefore, I will always be alone
  • I have acne, everyone will think I’m ugly
  • My skin is imperfect, no one will ever want to be my friend
These maladaptive beliefs in turn trigger negative emotions including anxiety, shame, disgust and guilt. In order to placate these negative emotions, individuals may either engage in avoidance (of people, places, situations) or rituals. Rituals are repetitive behaviours that may include mirror checking or excessive grooming, and reassurance seeking. According to this model, maladaptive beliefs, emotions, and behaviours are maintained through negative reinforcement. Put differently, these behaviours may reduce the impact behaviours over the short term. For instance, those who engage in repetitive reassurance-seeking may ask their partner for reassurance and experience temporary relief. Over the long term, however, these behaviours function to maintain maladaptive beliefs and negative views regarding oneself. Further, they may be extremely consequential and lead to fractured relationships. Furthermore, the model explains that several pathogenic factors also contribute to the onset and maintenance of the condition. These include biological factors such as genetics and neurobiological differences, but also temperamental and personality factors. Several factors that predict the onset of the condition include:
  • Sensitivity to rejection
  • Fear of negative evaluation
  • Childhood experiences
  • Cultural values
Considered the treatment of choice for body dysmorphic disorder, Cognitive Behavioural Therapy generally includes a combination of psychoeducation, cognitive restructuring and exposure and response (ritual) prevention (ERP). Collectively, this intervention seeks to target dysfunctional cognitions, avoidance, and neutralizing ritualistic behaviours.

Tailored Treatment Plans

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Dear Reader,
At IndoPsyCare, we formulate treatment plans on a case-by-case basis. Contingent upon your condition and situation, your therapeutic journey may or may not include a variation of the following components:
Assessments
Your therapist may administer assessments at various points throughout your therapeutic journey. This is done as a way of assessing your improvements and thus the effectiveness of the treatment plan. When treating body dysmorphic disorder, our clinicians typically administer several assessments including The Body Dysmorphic Disorder Questionnaire (BDD-Q) and the Yale-Brown OCD Scale adapted for Body Dysmorphic Disorder (BDD-YBOCS). Nevertheless, we ask that you please keep in mind that assessments may vary depending upon your specific condition.
Psychoeducation
Your therapist will seek to increase your understanding of social, cultural, biological, and psychological mechanisms that underlie and maintain body dysmorphic disorder. In addition, you may be taught to distinguish between "body image" and "physical appearance."
Cognitive Restructuring
During this phase, your therapist may help you identify and evaluate your negative appearance-related thoughts, perceptions and beliefs. Further, our clinicians may help you identify possible cognitive errors that underpin and perpetuate their maintenance. For instance, if you believe 'the stranger on the street looked at me distastefully because I am ugly', your therapist can help you identify the cognitive distortion that maintains this thought process (for instance, mind-reading: you don’t actually know what the person is thinking, or whether or not their expression had anything to do with you at all). During this stage, your therapist may also assist you in your ability to generate less harmful alternative explanations for your beliefs. For instance, your therapist can aid your ability to recognize that an individual's negative expression that you may have perceived as directed at you may have had nothing to do with you and more to do with their own life circumstances. For instance, perhaps they were simply having a bad day and were lost in their own thoughts when they unintentionally looked in your direction. Your therapist can assist you in your ability to find evidence, either in favour of or against, different alternative explanations.
Exposure and Response (Ritual) Prevention
Your clinician can assist you in your ability to become engaged in situations that would typically induce distress and maladaptive responses. Exposure and Response Prevention are usually combined to help reduce or eliminate your rituals. This may involve "graded tasks"; specifically, behaviours are incorporated hierarchically from the least distressing to the most distressing. For instance, your therapist may ask you to go out and buy groceries with no makeup on and ask that you do not repeatedly check your appearance. Next, they may ask that you attempt this at a breakfast event with your friends. The realization will likely become apparent that neither strangers on the street, nor any member of your friend group share your negative views about your perceived imperfections. In most cases, they will go completely unnoticed.
Mindfulness and Perceptual Retraining
Your therapist can guide you in the redirection of your attention and help you reappraise your physical appearance in a neutral, non-judgmental and holistic manner. For instance, you might be asked to describe yourself in neutral terms, for example, "I have black hair", "I have tan skin", and "I have brown eyes". In most cases, this phase involves the use of a mirror. Mirror training intends to "fix" your relationship with your reflection and develop control over your checking behaviours. Furthermore, during this stage, your therapist may aid you in retraining your attention. For instance, when you speak to people, your therapist may teach you techniques that will help you turn your attention outwards, as opposed to focusing on yourself and your perceived flaws. For example, instead of worrying “what do they think of my hair today? They must notice my imperfections”, you will gradually develop the ability to focus on the content of the conversation.
Addressing and altering maladaptive core beliefs
In combination, the phases involved in cognitive behavioural therapy can aid you in re-evaluating your views and core beliefs regarding your appearance.
Optional modules for specific issues
IndoPsyCare offers optional modules for specific issues. For instance, if you engage in skin-picking, your therapist may provide a habit-reversal module. If you suffer from depression, your therapist might integrate behavioural activation.
Relapse Prevention
During this phase, your therapist will reinforce your understanding of the strategies you have learned, including when and how they should be implemented. Furthermore, your therapist will typically teach you to recognize your own personal warning signs. It is essential that you understand these warnings so you can seek timely assistance from your therapist who will re-address your recovery treatment plan.

Treatment Duration

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How many sessions will I need?
Our psychologists base your treatment plan upon scientific literature and recommendations from bodies such as the Cochrane Library, the UK’s National Institute of Health and Care Excellence (NICE) and IPK Indonesia’s National Clinical Practice Guidelines. Whilst we generally recommend 16-24 weekly sessions, the number of sessions you require is typically influenced by:
  • The severity of your symptoms
  • Existing comorbidities (co-existing conditions)
  • The length of time you have been experiencing your condition
  • Your personal motivation and progress
  • Your social support network

Making the Most of Therapy

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Asking for help is commendable
Asking for help is understandably difficult, thus reaching out is a testament to the strength of each individual who does so. A call for help should never be seen as a sign of weakness, as it is the first step in your journey to recovery. Although sometimes uncomfortable, sharing your vulnerabilities with the right people may provide an appropriate, timely, and forthright avenue through which your problems can be assessed and addressed.
Be open and honest
Think of therapy as a journey in which you are steering the ship; your therapist is your guide, navigating the journey based on your account of what you see and experience. Reaching your desired destination and goals will be acquired with more proficiency when you share your feelings and fears. As your therapist acquires a clearer understanding of the intricacies of your situation, he or she will be in a better position to guide you in the right direction.
Be consistent
You will not see change overnight. True, lasting, cognitive and behavioural change takes time. Therapy is not a “quick fix”, rather it requires patience, consistency and tenacity on your part. Allow yourself time, communicate with your therapist, and share your feelings if you feel you are losing sight of your destination.
Trust the process
More often than not, improving your condition requires you to go beyond your comfort zone, letting go of your maladaptive coping strategies. Trust that, whilst this process may inevitably become uncomfortable or difficult at times, temporary discomfort may bring long-term and lasting benefits.

A Gentle Reminder

Dear Reader,
We sincerely appreciate your dedication; you have made it through this page of our library. We trust that you have gleaned valuable information from this page. Before we part ways we would like to reiterate that each treatment plan will be uniquely tailored to you, your situation and your requirements. Your personal treatment plan may or may not include the elements on this page. If you feel as though you require professional assistance, please refrain from self-diagnosis. IndoPsyCare has professionals who are here to help.

Resources and Recommended Readings

NICE Guidelines

National Institute for Health and Care Excellence. (2022). Obsessive-compulsive disorder and body dysmorphic disorder: treatment. Retrieved 1 July 2022, from https://www.nice.org.uk/guidance/cg31

ICD-11 Criterion

World Health Organization. (2019). ICD-11: International Classification of Diseases (11th revision). Retrieved from https://icd.who.int/ Code for Body Dysmorphic Disorder: 6B21

Further Reading

Bjornsson, A. S., Didie, E. R., & Phillips, K. A. (2010). Body dysmorphic disorder. Dialogues in clinical neuroscience, 12(2), 221–232. https://doi.org/10.31887/DCNS.2010.12.2/abjornsson Fang, A., & Wilhelm, S. (2015). Clinical Features, Cognitive Biases, and Treatment of Body Dysmorphic Disorder. Annual Review Of Clinical Psychology, 11(1), 187-212. doi: 10.1146/annurev-clinpsy-032814-112849 Phillips, K. A., Menard, W., Fay, C., & Pagano, M. E. (2005). Psychosocial functioning and quality of life in body dysmorphic disorder. Comprehensive Psychiatry, 46(4), 254–260. https://doi.org/10.1016/j.comppsych.2004.10.004 Veale, D. (2000). Outcome of cosmetic surgery and ‘DIY’ surgery in patients with body dysmorphic disorder. Psychiatric Bulletin, 24(6), 218-221. doi:10.1192/pb.24.6.218

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