Although body dysmorphic disorder (BDD) has been described in the literature for more than a century, there has been only a limited focus on the development of cognitive behavioral treatments for BDD. Our case report provides a detailed description of a course of cognitive behavioral treatment (CBT) for an individual with BDD. The patient was treated for 10 weekly 50-minute individual sessions. The treatment focused on psychoeducation, cognitive restructuring, exposure and response prevention, and perceptual retraining exercises. The patient's BDD symptoms significantly improved over the course of the treatment. This case study illustrates several clinical strategies and provides further support for CBT as a promising treatment for individuals suffering from BDD.
Despite the recent increase in public awareness regarding body dysmorphic disorder (BDD), effective treatment options are underutilized and require further elucidation. Classified as a somatoform disorder in the DSM-IV, BDD is characterized by a preoccupation with imagined or slight defects in physical appearance ( American Psychiatric Association [APA], 1994), which leads to significant distress and/or social or occupational impairment. Patients with BDD are reluctant to discuss appearance concerns, and subsequently live alone in shame and despair with their symptoms. Although individuals may eventually seek treatment for comorbid psychiatric disorders, they often do not disclose BDD symptoms to clinicians. It is critical for health providers to specifically screen patients for appearance-related concerns to prevent BDD symptoms from continuing to go unnoticed and untreated.
Clinicians can start screening for BDD by asking patients about potential worries they may experience about any part of their appearance. The most common preoccupations involve the face or head, including the skin (e.g., scarring), hair (e.g., thinning hair), or nose (e.g., shape or size), but any body part may be the focus of concern (e.g., Phillips, McElroy, Keck, Pope, & Hudson, 1993). Although shape and weight concerns are common among BDD patients, if concerns are exclusively related to weight/shape, an eating disorder assessment may be warranted. Intrusive appearance- related thoughts are time-consuming and upsetting, and lead individuals to engage in compulsive behaviors (i.e., mirror checking, comparing themselves to others, camouflaging, excessive grooming, skin picking)—which often take up several hours a day—in an attempt to alleviate distress (e.g., Phillips et al., 1993). Individuals often go out of their way to avoid certain situations, people, or places. Avoidance can be so severe that patients become nearly or completely housebound. Insight is often very limited, and the appearance-related beliefs of nearly half of patients are delusional (Phillips, 2004 and Phillips et al., 2005). In a recent examination of clinical features in 164 adults with BDD (Phillips, Didie et al., 2006), current delusionality was reported in about one-third of the sample (33.1%, n = 45) and 75.6% (n = 124) reported lifetime delusionality. Almost half of the sample (45.7%, n = 75) reported delusional ideas of reference, for example, being convinced that others are laughing about or staring at their perceived flaw ( Phillips, Didie, et al., 2006). More than 60% of patients with BDD ( Gunstad and Phillips, 2003 and Phillips and Menard, 2006) suffer from comorbid depression and are at high risk of suicide. A recent 4-year prospective study of 185 BDD patients ( Phillips & Menard, 2006) found annual rates of suicidal ideation (57.8%) and attempts (2.6%) to be markedly high; the annual completed suicide rate among BDD (0.3%) patients is approximately 45 times higher than that in the general U.S. population ( Phillips & Menard, 2006).
