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.
Body dysmorphic disorder (BDD) is a severe body image disorder consisting of an often-delusional preoccupation with an imagined or slight defect in appearance (American Psychological Association, 1994). This preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, and it is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa). BDD is a common disorder; nationwide surveys have found a point prevalence of 1.7 to 2.4% (Buhlmann et al., 2010, Koran et al., 2008 and Rief et al., 2006). BDD usually begins during early adolescence (Phillips and Diaz, 1997 and Phillips et al., 2006a) and, when untreated, the disorder is often chronic and unremitting (Phillips, Pagano, Menard, & Stout, 2006). BDD is associated with high lifetime rates of psychiatric hospitalization (48%), being housebound (31%; Phillips & Diaz, 1997), and high rates of suicidality. In cross-sectional studies, lifetime suicidal ideation rates are 78–81%, and lifetime suicide attempt rates are 24–28% (Perugi et al., 1997, Phillips et al., 2005a, Phillips and Diaz, 1997, Phillips and Menard, 2006 and Veale et al., 1996a). This suicide attempt rate is 6–23 times higher than in the U.S. population. Completed suicide has been reported (Atiullah and Phillips, 2001, Cotterill, 1981, Cotterill and Cunliffe, 1997, Phillips and Menard, 2006, Veale et al., 1996a and Yamada et al., 1978). When controlling for age, gender, and geographic region, the standardized mortality ratio is markedly elevated (American Psychiatric Association, 2003 and Harris and Barraclough, 1997). Despite BDD's relatively high prevalence and substantial morbidity, no widely applicable manualized psychosocial treatment has been tested for this complex disorder.
Treatments for other disorders are not applicable to BDD because there are important differences between symptoms of BDD and those of other disorders (Phillips, 2005). Differences include the content of the preoccupation (appearance), specific repetitive and avoidance behaviors (e.g., surgery seeking, mirror checking, skin picking, compulsive grooming), perceptual distortions, and poor insight, which are typically present in BDD but not disorders such as obsessive-compulsive disorder (Eisen, Phillips, Coles, & Rasmussen, 2004). Thus, a treatment that specifically targets BDD's unique symptoms is greatly needed.
