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Cognitive–behavioural therapy for body dysmorphic disorder

body dismorphic disorderAPT (2001), vol. 7, p. 125 Advances in Psychiatric Treatment (2001), vol. 7, pp. 125 132 The DSM IV classification of body dysmorphicdisorder (BDD) refers to an individual s preoccu-pation with an imagined defect in his or herappearance or markedly excessive concern with aslight physical anomaly (American PsychiatricAssociation, 1994). An Italian psychiatrist, Morselli,first used the term dysmorphophobia in 1886,although it is now falling into disuse, probablybecause ICD 10 (World Health Organization, 1992)has discarded it, subsuming the condition underhypochondriacal most common preoccupations are with thenose, skin, hair, eyes, eyelids, mouth, lips, jaw andchin. However, any part of the body may be involvedand the preoccupation is frequently focused onseveral body parts.

Body dismorphic disorder Advances in Psychiatric Treatment (2001), vol. 7, pp. 125–132APT (2001), vol. 7, p. 125 The DSM–IV classification of body dysmorphic disorder (BDD) refers to an individual’s preoccu-pation with an ‘imagined’ defect in his or her

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Transcription of Cognitive–behavioural therapy for body dysmorphic disorder

1 body dismorphic disorderAPT (2001), vol. 7, p. 125 Advances in Psychiatric Treatment (2001), vol. 7, pp. 125 132 The DSM IV classification of body dysmorphicdisorder (BDD) refers to an individual s preoccu-pation with an imagined defect in his or herappearance or markedly excessive concern with aslight physical anomaly (American PsychiatricAssociation, 1994). An Italian psychiatrist, Morselli,first used the term dysmorphophobia in 1886,although it is now falling into disuse, probablybecause ICD 10 (World Health Organization, 1992)has discarded it, subsuming the condition underhypochondriacal most common preoccupations are with thenose, skin, hair, eyes, eyelids, mouth, lips, jaw andchin. However, any part of the body may be involvedand the preoccupation is frequently focused onseveral body parts.

2 Complaints typically involveperceived or slight flaws on the face, the size of bodyfeatures (too small or too big), hair thinning, acne,wrinkles, scars, vascular markings, paleness orredness of the complexion, asymmetry or lack ofproportion. Sometimes the complaint is extremelyvague; it may amount to no more than the patientfeeling generally dysmorphic disorder has never been inclu-ded in the large catchment-area surveys of psychi-atric morbidity. However, one Italian study ofsomatoform disorders found a 1-year prevalence ofBDD of nearly 1% (Faravelli et al, 1997). This wouldmake it relatively common, but mental healthprofessionals do not often diagnose and treatpatients with BDD. It is a hidden disorder for whichmany people do not seek help.

3 There is therefore alow level of awareness of BDD among both thepublic and health professionals. When people doseek help they are likely to consult a dermatologistor cosmetic surgeon. For example, Sarwer et al (1998)found that 5% of women presenting at a cosmeticsurgery clinic in the USA had BDD. If people withBDD do seek help from a general practitioner ormental health professional, they are often tooashamed to reveal their main symptoms and presentwith symptoms of depression or social phobia: onlyspecific questioning reveals BDD. Patients areespecially secretive about symptoms such as mirror-gazing, probably because they fear they will bethought vain or average, BDD is diagnosed 10 years after firstpresentation and it is often treated inappropriatelywith antipsychotic medication (Phillips, 1998).

4 Psychotherapists may have little experience intreating BDD patients or lack an effective treatmentmodel. Two randomised controlled trials (RCTs)have been conducted in BDD for cognitive behavioural therapy (CBT) against a waiting list(Rosen et al, 1995; Veale et al, 1996a) and several caseseries (Neziroglu & Yaryura Tobias, 1993; GomezPerez et al, 1994; Wilhelm et al, 1999). Evidence existsfor the efficacy of selective serotonin reuptakeinhibitors (SSRIs) in the treatment of BDD (Hollanderet al, 1999); this is discussed assessmentBeliefs about appearance (for example, that one snose is too crooked) may be held with poor insightCognitive behavioural therapyfor body dysmorphic disorderDavid VealeDavid Veale is an honorary senior lecturer at the Royal Free Hospital and University College Medical School, University CollegeLondon and a consultant psychiatrist at The Priory Hospital North London (Grovelands House, The Bourne, Southgate,London N10 3NA.)

5 E-mail: His main interests are in cognitive behavioural therapy and its application toanxiety (2001), vol. 7, p. 126 Veale(having overvalued ideas) or no insight (beingdelusional). Within the DSM IV classification ofBDD, the strength of such beliefs is used to determinewhether there is an additional (or in ICD 10, analternative) diagnosis of delusional disorder . TheDSM IV diagnostic criteria state that if preoccu-pation with a minor physical anomaly is presentthen the person s concern is regarded as markedlyexcessive . To distinguish BDD from normal con-cerns about appearance (especially during adoles-cence), a preoccupation must also cause significantdistress or handicap. Phillips (1996) suggests thatto justify a diagnosis of BDD, preoccupation with imagined defects in appearance should last at least1 hour a of life measures found a degree of distressin BDD that is worse than that in depression(Phillips, 2000).

6 People with the disorder are oftenunemployed or disadvantaged at work, houseboundor socially isolated because of their handicap. A riskassessment must be done, as there is a high rate ofsuicide and self-harm (Veale et al, 1996b) and do-it-yourself cosmetic surgery (Veale, 2000). There isfrequent comorbidity, with secondary diagnoses ofdepression, social phobia, obsessive compulsivedisorder or personality disorder (Veale et al, 1996b).Not surprisingly, BDD patients are difficult to engageand behaviouralassessmentA cognitive behavioural assessment uses a three-systems analysis, concentrating on the factors thatmaintain the disorder , in particular, beliefs are often dissatisfied with many areas oftheir body . Asking them to complete a checklist ofdifferent parts of the body , saying exactly what theybelieve is defective about each part, how they wouldlike it to be and the proportion of distress that iscauses can clarify their concerns.

7 The nature of thepreoccupation may fluctuate over time, which mayexplain why, after cosmetic surgery, a preoccupationoften shifts to another area of the next step is to assess the personal meaning orthe assumptions held about the perceived defect orugliness. Patients may have difficulty in articulatingthe meaning, and a downward-arrow technique can usually identify such assumptions; aftereliciting the most dominant emotion associated withthinking about the defect, the therapist asks what isthe most shameful (or anxiety-provoking) aspectabout the defect. For example, one patient mightbelieve that having a defect affecting his nose willmean that he will end up alone and unloved. Anothermight believe that the most disgusting aspect offlaws in her skin is that they make her look assumptions are then used in cognitiverestructuring and behavioural values most important to the individualshould also be identified.

8 In BDD, appearance isalmost always the dominant and idealised valueand the means of defining the self. Patients implicit-ly view themselves as aesthetic objects . Otherimportant values in BDD include perfectionism,symmetry and social acceptance, and they may takethe form of certain rules, for example I have to besymmetrical .BehavioursMirror-gazing is at the core of BDD and it appearsto be a complex series of safety behaviours. However,mirror-gazing is not even described in standardtextbooks of psychopathology. Why do some BDDpatients spend many hours in front of a mirror whenit invariably makes them feel more distressed andself-conscious? A colleague and I recently conducteda study comparing mirror-gazing in patients withBDD and in normal controls (Veale & Riley, 2001).

9 We concluded that patients main motivations formirror-gazing are: the hope that they will lookdifferent; the desire to know exactly how they look;to see how well efforts at camouflage have worked;and a belief that they will feel worse if they resistgazing (although gazing in fact increases distress).Patients were more likely to focus their attention onan internal impression or feeling (rather than ontheir reflection in the mirror) and on specific partsof their appearance. Although both patients andcontrols used the mirror for normal actions (to puton make up, shave, groom their hair or check theirappearance), only patients performed mentalcosmetic surgery to change their body image andpractised pulling different faces. A detailedassessment of patients behaviour in front of a mirrorand their motivation is of great value for therapyand for the construction of behavioural experimentsto test out beliefs.

10 For example, the duration of thelongest mirror-gazing session and the frequency ofthe shorter sessions can be used throughout therapyto monitor the severity of the behaviour. Otherreflective surfaces, such as the back of compact disksand shop window-panes, may also be used, whichdistort the body image in dismorphic disorderAPT (2001), vol. 7, p. 127 Patients may also check their appearance bymeasuring their perceived defect, by feeling thecontours of the skin or by taking frequent photo-graphs or video recordings of themselves. Otherbehaviours include asking others to verify theexistence of the defect or the effectiveness ofcamouflage; comparing current appearance withold photographs or with the apperance of otherpeople; wearing make-up 24 hours a day; excessivegrooming of the hair; excessive cleansing of the skin;use of facial peelers, saunas or exercises to improvefacial muscle tone; beauty treatments ( collageninjections to the lips); cosmetic surgery; anddermatological treatments.


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