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Abstract Social anxiety disorder and body dysmorphic disorder are considered nosologically distinct disorders. In contrast, some cognitive models suggest that social anxiety disorder and body dysmorphic disorder share similar cognitive maintenance factors. The aim of this study was to examine the effects of psychological treatments for social anxiety disorder on body dysmorphic disorder concerns. In Study 1, we found that 12 weekly group sessions of cognitive-behavioral therapy led to significant decreases in body dysmorphic symptom severity. In Study 2, we found that an attention retraining intervention for social anxiety disorder was associated with a reduction in body dysmorphic concerns, compared to a placebo control condition. These findings support the notion that psychological treatments for individuals with primary social anxiety disorder improve co-occurring body dysmorphic disorder symptoms.

Introduction A growing body of research suggests that BDD shares some similarities with social anxiety disorder (SAD) in diagnostic features, demographic characteristics, course and onset, clinical characteristics, and treatment outcome (Fang and Hofmann, 2010, Fang et al., 2011 and Kelly et al., 2010). Prevalence studies show that among individuals with SAD, 4.8–12% also meet criteria for BDD, and among individuals with BDD, 12–68.8% also meet criteria for SAD (Fang & Hofmann, 2010). Historically, most of the research on body dysmorphic disorder (BDD) has emphasized its relationship to obsessive-compulsive disorder (OCD). Cognitive models of both OCD and BDD propose that maladaptive cognitions maintain and exacerbate these disorders (Rachman, 1997, Wilhelm and Neziroglu, 2002 and Wilhelm and Steketee, 2006). A further discussion of the relationship between BDD and OCD, and the inclusion of BDD on the putative obsessive-compulsive spectrum is discussed elsewhere (for a review, see Phillips et al., 2010). The current paper will focus on the relationship between BDD and SAD. Several models of BDD have strong theoretical overlap with models of SAD. For example, cognitive-behavioral models of BDD emphasize dysfunctional cognitive processes (e.g., negative appraisals of body image, self-focused attention, post-event rumination) and maladaptive behaviors that maintain BDD (e.g., mirror checking, social avoidance, comparing appearance with others) (Veale, 2004 and Wilhelm et al., 2013), which are consistent with processes that are proposed to maintain SAD (Hofmann, 2007 and Rapee and Heimberg, 1997). In particular, cognitive-behavioral models of BDD highlight the cognitive aspects of the disorder such as the view of oneself as an esthetic object, which contributes to distorted mental imagery from an observer perspective, self-focused attention, meta-cognitions about the importance of self-focused attention, and a loss of a self-serving bias (Neziroglu, Khemlani-Patel, & Veale, 2008). This literature shares strong similarities with cognitive behavioral models of SAD, which emphasize the view of the self as a social object and leads to hypervigilance of social threat cues (Clark and Wells, 1995, Hofmann, 2007 and Rapee and Heimberg, 1997). For both BDD and SAD, it may be that the mental representation of the self is generated from both internal cues (e.g., physical symptoms) and external environmental cues (e.g., facial expressions). In a study of BDD among individuals with anxiety disorders, Wilhelm, Otto, Zucker, and Pollack (1997) found that BDD was most common among individuals with SAD (12%) and less common among individuals with OCD (7.7%), generalized anxiety disorder (6.7%), and panic disorder (1.5%). Moreover, among all individuals with comorbid SAD and BDD in that study, the onset of SAD preceded that of BDD. This suggests that the presence of SAD may be related to the development of subsequent BDD concerns. Taken together, these findings suggest that BDD symptoms may be elevated among individuals with SAD and that SAD may be a risk factor for the development of BDD symptoms and full-blown BDD. The treatment outcome literature further suggests that cognitive-behavioral therapy (CBT) is an efficacious psychological treatment for both BDD (e.g., Veale et al., 1996 and Wilhelm et al., 1999) and SAD (e.g., Hofmann & Otto, 2008). One study, which examined the effect of CBT for BDD and included SAD symptom outcome measures, found that compared to the wait list control group, individuals who received CBT had significantly less SAD symptoms at post-treatment (Veale et al., 1996). To our knowledge, no study has yet investigated the effect of CBT for SAD on BDD symptoms. Furthermore, attentional mechanisms have been the subject of much research attention for both disorders. One study suggested that individuals with BDD selectively attended to appearance-related information and emotional appearance-unrelated information (Buhlmann, McNally, Wilhelm, & Florin, 2002). Similarly, studies suggest that individuals with SAD have an attentional bias, as demonstrated by faster detection of probes replacing social threat words than of those replacing neutral or positive words in a modified dot-probe paradigm (Amir, Elias, Klumpp, & Przeworski, 2003). As such, an emerging line of research has begun to evaluate the potential therapeutic benefit of modifying attentional biases in SAD using attention bias modification interventions (Amir, Weber, Beard, Bomyea, & Taylor, 2008). Studies suggest that attention bias modification interventions, or attention retraining, leads to significantly reduced attentional biases in individuals with SAD, and improves social anxiety symptom severity (Amir et al., 2009, Amir et al., 2008 and Schmidt et al., 2009). Recent meta-analyses, however, suggest that there may be mixed evidence for the efficacy of cognitive bias modification, and that the effect size of attention retraining for anxiety disorders may be smaller than what other studies suggest (Beard et al., 2012 and Hallion and Ruscio, 2011). Nevertheless, attention retraining is relevant to explore in BDD given the hypotheses set forth by cognitive-behavioral models of BDD that individuals with BDD may be particularly attentive to threatening cues with a socio-evaluative component (e.g., threatening faces), and in light of existing evidence showing an attentional bias to appearance-related information. The purpose of the current paper was to examine the effect of CBT and attention retraining for SAD on BDD-related cognitions and symptoms in individuals with a primary diagnosis of SAD. In Studies 1 and 2, we examined the effect of group CBT for SAD (Study 1) and an attention retraining intervention for SAD (Study 2) on BDD symptoms. We hypothesized that treatment in both studies would lead to a significant reduction of overall BDD symptoms in patients with primary SAD and co-occurring subclinical symptoms of BDD. In both studies, BDD symptoms were measured using the Body Dysmorphic Disorder Symptom Scale (BDD-SS; Wilhelm, 2006 and Wilhelm et al., 2013), which provides an overall severity score, as well as scores in seven different symptom domains. In particular, we hypothesized that the symptom domain reflecting BDD-related cognitions, or the “beliefs about appearance” subscale, would be significantly reduced following treatment in both studies.

5. Conclusions This was the first study to examine the effect of two psychological treatments for SAD on co-occurring BDD concerns. Our findings suggest that both cognitive-behavioral therapy and attention retraining appeared to improve body dysmorphic concerns in patients with a primary diagnosis of SAD. Although the constructs of SAD and BDD share much conceptual overlap, our findings provide empirical support that the two constructs are distinguishable and may partly be maintained by separate mechanisms. Further research is needed with patients with a diagnosis of BDD to confirm these findings, and to clarify the mechanism through which these disorders are linked.