Neziroglu BDD Presentation Part 4

  1. Behavioral Treatment Steps
  • Step 1: Build A Hierarchy
  • Targeting avoidance.
  • Targeting distressing situations.
  • Question patient about a typical day to elicit hierarchy items.


  1. Building a Hierarchy
  • Common Distressing Situations
  • Mirrors/Shiny surfaces
  • Outdoors and bright lighting
  • Crowded situations with little personal space
  • Shopping centers
  • Haircuts
  • Summer time activities
  • Shopping for clothes
  • Classroom environment
  • Sports activities (swimming)


  1. Bill’s Hierarchy
  • Watching himself on his sister’s wedding video
  • 20 In session with therapist without hat for 1 min.
  • 25 Driving in car with styled hair without hat
  • 30 Sitting in last row of movie theater without hat
  • 40 In session with therapist without hat for 15 mins.
  • 50 Dining in dimly lit restaurant without hat
  • 60 Sitting in clinic waiting room without hat
  • 70 Going out with friends without hat
  • 80 At home with extended family without styled hair without a hat
  • 80 Shopping in a supermarket with or without styled hair without a hat
  • 90 Going to the Barber Shop for a hair cut
  • 100 Physical activity in a crowded park without hat


  1. Behavioral Treatment Steps
  • Step 2: Decrease Compulsive Behaviors (Response Prevention)
  • Initially patient may be asked to cover all mirrors in home.
  • Give up all cosmetic products.
  • Give up special “tools” for skin picking.
  • Step 3: Initial Exposure Exercises
  • Gradually expose area of concern
  • Step 4: Exposure Exercises with Exaggeration of the Perceived Flaw
  • Use of make-up, clothes etc. to highlight or exaggerate defect paired with gradual exposure to anxiety provoking situations.
  • Step 5: Mirror Re-Training

▫         Teaching patient to describe appearance in less subjective language.

▫         Teaching patient how to scan their appearance without spending too much time on one particular body part.

▫         Teaching patients not to focus and examine details of appearance.


  1. Mirror Retraining
  • Identify motivation and criteria for termination
  • Goals for agreed function
  • Use large mirror at slight distance & non-judgemental
  • Minimal or no make up
  • Focus attention on external reflection
  • Scan whole of face or body
  • Use a variety of mirrors & lights
  • No magnifying mirrors
  • Delay response when urge


  1. Attentional Exercises
  • Situational refocusing – goal is to refocus attention externally, “focus on the what you can see, hear, smell, textures” or “interrogate the environment” (Clark, Wells, Bogels)

1) In vivo in session in which patient compares the effect of self-focused attention on preoccupation and distress

2) Homework monitor focus and depth of attention in different contexts

3) Behavioral experiment (increase and decrease self-focus attention)

4) Identify and help client question helpfulness of beliefs about self-focused attention


  1. Attentional Exercises: Exploring Assumptions about Self-Focused Attention
  • What is the motivation for being self-focused? Do you feel that being self-focused will help you?
  • Do these assumptions help you live by your goals and values?
  • Would you recommend to other people that they be self-focused? Why?
  • Is it possible that others may see you differently than the picture in your mind? What do you feel influences your impression of your self over time?
  • What are your doubts about being externally focused?
  • Can you make an alternative assumption about being self-focused? (By actively making alternative assumptions you are challenging your initial assumptions about the functional purpose of self-focused attention).


  1. Attentional Exercise: Functional Analysis of Self-Focused Attention
  • Activating Event
  • Please describe a recent situation in which you were self-focused
  • Behavior
  • Please describe what you were doing to be excessively self-focused.
  • Intended Consequences
  • Before you started being self-focused, what did you want to accomplish?


  • Immediate Consequence
  • Was there a positive outcome for being self-focused? Did you feel you were doing something to prevent something bad from happening? For example, Were you trying to prevent being humiliated?
  • Unintended Consequence
  • What effect did being self-focused have? Did it make you more preoccupied with your appearance? Did it make you more anxious?
  • What effect did being self-focus have on your friends and family?
  • Alternative Directions
  • Would being externally focused be more consistent with your values and goals?


  1. Task Concentration Training
  • Extension of situational re-focussing
  • Originally developed for social anxiety to redirect attention towards task in situation
  • Task concentration training consists of three phases
  1. a) Gaining insight in the role of attention and the effects of heightened self focused attention
  2. b) Focusing attention outward in non-threatening situations
  3. c) Focusing attention outward in threatening situations


  1. Task Concentration Training
  • The first step is to monitor the degree of attention in different contexts in a diary. This would record:
  1. a) Situations that trigger distress and preoccupation
  2. b) The degree of anxiety or distress
  3. c) The percentage of concentration that was directed towards each of the three elements: the self, the task, and the environment, at that moment


  1. Task Concentration Training Exercises
  • Listening exercise (no eye contact, then with eye contact)
  • Speaking exercise
  • Non-threatening situation
  • Threatening situations
  • Adapt to non-social situations –watching TV, mirror


  1. More on Intrusive Imagery
  • Identify beliefs about imagery (e.g. “The picture in my mind is a reflection of how I look”)
  • Aim to develop different relationship with memory where it’s just a bad memory rather than something that is relevant now
  • Functional analysis on response to intrusive images. Avoid or check? What are the unintended consequences of response?
  • Occasionally flash forwards


  1. Family Involvement
  • Psycho-education
  • Group therapy
  • Reduce family’s frequency of providing reassurance
  • Reduce family’s accommodating or antagonistic styles
  • Teach family to be a co-therapist/coach for ERP exercises


  1. Pharmacotherapy and BDD
  • Effective

o       Clomipramine

o       Fluoxetine

o       Fluvoxamine

o       Pimozide

o       Consider newer SRI’s (Venlafaxine, Citalopram, Lexapro)

  • Ineffective

o       Imipramine

o       Diazepam

o       Trazedone

o       Lithium

o       Alprazolam

o       ECT


  1. Pharmacologic treatment of BDD
  • Research on pharmacotherapy received by individuals with body dysmorphic disorder (BDD) is limited, though it appears that the use of anti-depressants has the most effect in treatment of BDD
  • 72.9% of 151 subjects had received psychotropic medication.


  • Most common type ever received was an SRI (65.6%), followed by non-SRI antidepressants (41.1%) and benzodiazepines (27.2%).
  • Phillps et al. (2006)
  • Subjects with lifetime OCD or greater lifetime impairment due to BDD were more likely to have received an SRI specifically.
  • Only 12.9% of SRI trials were considered optimal for BDD, and an additional 21.5% were considered minimally adequate.


  1. A Call for New Treatment Options
  • When an individual fails to respond to treatment we as professionals:
  • offer them more intense or frequent CBT

▫         higher dosages or different SSRIs


  1. The Third Wave
  • Mindfulness based and contextually focused therapeutic interventions
  • Dialectical Behavior Therapy (Linehan, 1993)
  • Functional Analytic Psychotherapy (Kohlenberg & Tsai, 1991)
  • Mindfulness-Based Cognitive Therapy (Segal, Williams, & Teasdale, 2002)To continue reading, click here