Cognitive)ehavioral body image therapy for body dysmorphic disorder.

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Abstract
Body dysmorphic disorder (BDD) is a distressing body image disorder that involves excessive pre- occupation with physical appearance in a normal appearing person. Prior case reports of behavior therapy were encouraging, but no controlled evaluation of behavior therapy or any other type of treatment had been conducted. In the present study, 54 BDD subjects were randomly assigned to cognitive behavior therapy or no treatment. Patients were treated in small groups for eight 2-hour sessions. Therapy involved modification of intrusive thoughts of body dissatisfaction and overvalued beliefs about physical appearance, exposure to avoided body image situations, and elimination of body checking. Body dysmorphic disorder symptoms were significantly decreased in therapy sub- jects and the disorder was eliminated in 82% of cases at posttreatment and 77% at follow-up. Overall psychological symptoms and self-esteem also improved in therapy subjects. Although body dissatisfaction seems almost normal today, concern with physical appearance is truly distressing and dis- abling for a significant number of people. The category of the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 1987, 1993) that accommo- dates this problem of body image disorder is body dysmorphic disorder (BDD). The prevalence of BDD is approximately 4% in women and less than 1% in men (Rich, Rosen, Orosan, & Reiter, 1992). Although it is not a rare disorder, only a few case studies of BDD treatment have been reported. Some treatments appear promising, but none has been subjected to an experi- mentally controlled evaluation using standardized measures. That was the objective of the present study. BDD patients can be distressed about virtually any aspect of their physical appearance (Phillips, 1991), though they are normal appearing. Complaints about the size, shape, or sym- metry of facial features are common. Some patients report con- cerns about skin blemishes, breast size or symmetry, thinning hair or excessive body hair, teeth, and genitals. Others have more vague complaints such as being "ugly." Dislike of body weight or shape is common today, but these complaints can reach the level of BDD if accompanied by distressing and disabling pre- occupation (Crisp, 1988). Like other somatoform disorders, the essence of BDD is not where in the body the patient sees the defect, but the fact that the patient is preoccupied with it. Appearance preoccupation occurs mostly in social situations in which the person feels self-conscious and expects to be scru-

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