BDD patient: “Well, I haven’t had a date for a long time. I think this is evidence that my (body part) must be ugly, and that no one wants to date me because of it.”
Therapist: “What are some other possible reasons why you haven’t had a date in a long time? You admitted that you have barely left your house for many months. Is it possible that you have not had a date for a long time because you rarely go outside?”
With cognitive restructuring, patients learn to:
- identify automatic thoughts and beliefs that provoke distress
- examine evidence supporting or refuting these beliefs
- de-catastrophize (such as “What is the worst thing that could happen if you left the house today without checking your [body part]? Do you think you would eventually be able to cope with that?”)
- learn to more accurately assess the probability of feared negative consequences
- arrive at rational responses.
In our experience—which is supported by OCD literature—participating in CBT is very hard for patients with frank delusions, and insight determines how effective cognitive restructuring can be.30 If a patient is convinced a body part is defective, she is unlikely to stay in treatment—much less be open to restructuring her thoughts. Even unsuccessful attempts can help you gauge the intensity of patients’ beliefs, however.
During cognitive restructuring, it is important to uncover patients’ core beliefs (underlying, organizing principles they hold about themselves, others, and the world). BDD patients commonly believe that appearance is of utmost importance and that no one could love them because of their “defect.” The therapist can then help the patient challenge the rationality of those core beliefs.
Behavioral therapy. Basic behavioral therapy attempts to normalize excessive response to appearance concerns and to prepare patients for exposure and response prevention therapy (ERP). Having identified their compulsions, the next step is to guide patients in changing these behaviors, such as by:
- decreasing reassurance-seeking
- reducing avoidance of social situations
- decreasing opportunities to use the mirror
- reducing time spent on the Internet seeking cosmetic solutions
- increasing eye contact in social situations
- decreasing scanning of others’ physical features.
For example, suggest that BDD patients stand at least an arm’s length away when using a mirror for normal grooming. Then, instead of focusing on their body part, they will view it within the context of their entire face and body.
Exposure and response prevention
ERP exposes the patient to situations that evoke negative emotions—primarily shame and anxiety in BDD—so that they gradually habituate to these feelings. Individualize exposure exercises, targeting the body parts each person believes are defective. Because these exercises are intended to induce the discomfort patients usually experience, do not attempt ERP until the patient has had extensive education, developed insight, and has consented to treatment.
Create a hierarchy of ERP tasks (Table 5), ranking situations from low- to high-distress. Address items lower on the hierarchy first, and progress to higher items as the lower ones become easier to perform. Do not attempt the highest-distress items until the patient has improved insight and is not severely ill and suicidal.
During exposures, patients must remain in distress-provoking situations—without performing compulsive behaviors—until their negative feelings decrease by at least 50% of the initial subjective, self-rated distress level. Leaving the situation before stress diminishes may reinforce shame and discomfort. Performing compulsive behaviors during or after an exposure will negate the exposure’s effect.
Mirrors and ERP. Some therapists use mirrors for exposure exercises, but this is a complex issue. Mirror-checking is a common BDD compulsion that provides temporary relief but ultimately reinforces negative, intrusive thoughts about the disliked body area. How BDD patients perceive themselves changes from moment to moment; they may stare at and analyze any reflective surface in hopes that their “defect” will not appear as deformed or ugly that day. Thus, one cannot predict whether looking in the mirror at any one time is an exposure or a compulsion.
ERP exercises for BDD need to emphasize behaviors that involve interactions with the outside world, rather than reinforcing the importance of appearance. Using the mirror for ERP could promote checking compulsions and may send the message that appearance is the focal point of treatment. On the other hand, for patients with persistent mirror avoidance, gradual mirror exposures may be useful. A technique called mirror retraining helps patients objectively view their appearance and has been used with success in some individuals.
Table 5
Exposure and response therapy: a BDD patient’s sample hierarchy
| High-distress tasks | Subjective distress rating (scale of 0 to 100) |
| 1. Purposely creating the appearance of acne/skin defects | 100 |
| 2. Intentionally messing up my hair before going in public | 100 |
| 3. Standing under bright or fluorescent lighting in public | 90 |
| 4. Sitting in a position where others can directly see my face for an extended period | 85 |
| 5. Highlighting my face with a flashlight or bright light, while sitting in front of my therapist or another person. | 80 |
| Lower-distress tasks | |
| 6. Intentionally going outside in daylight hours, instead of only after dark | 70 |
| 7. Not turning away from others in an attempt to prevent them from seeing my face | 65 |
| 8. Standing close to people when talking to them, rather than standing at a distance | 50 |
| 9. Going out in public without camouflaging my hair with hats or scarves | 40 |