Inference‐Based Therapy for Body Dysmorphic Disorder

Abstract

Body dysmorphic disorder (BDD) is a debilitating disorder characterized by an excessive preoccupation with an imagined or very slight defect in one's physical appearance. Despite the overall success of cognitive behavioural therapy (CBT) in treating BDD, some people do not seem to benefit as much from this approach. Those with high overvalued ideation (OVI), for instance, have been shown to not respond well with CBT. The purpose of this study was to evaluate the efficacy of an inference-based therapy (IBT) in treating BDD. IBT is a cognitive intervention that was first developed for obsessive-compulsive disorder with high OVI, but whose focus on beliefs can also apply to a BDD population. IBT conceptualizes BDD obsessions (e.g., 'I feel like my head is deformed') as idiosyncratic inferences arrived at through inductive reasoning processes. Such primary inferences represent the starting point of obsessional doubt and the treatment focuses on addressing the faulty inferences that maintain the doubt. Thirteen BDD participants, of whom 10 completed, underwent a 20-week IBT for BDD. The participants improved significantly over the course of therapy, with large diminutions in BDD and depressive symptoms. OVI also decreased throughout therapy and was not found to be related to reduction in BDD symptoms. Although a controlled-trial comparing CBT with IBT is needed, it is proposed that IBT constitutes a promising treatment alternative for BDD especially in cases where OVI is high. KeywordsBody Dysmorphic Disorder; Inference-Based Approach; Inference-Based Therapy; Overvalued Ideation; Cognitive Therapy Body dysmorphic disorder (BDD) is characterized by an excessive pre-occupation with an imagined or very slight defect in physical appearance. Although concerns can relate to body weight or shape, they should not be better accounted for by another mental disorder such as anorexia nervosa or bulimia (American Psychiatric Association, 2000). Any body part can become the focus of concern but the most common parts are the skin, hair, nose, weight and stomach (Phillips, 2005). BDD is associated with markedly poor psychosocial functioning and low quality of life (Phillips, Menard, Fay, & Pagano, 2005) and with high levels of suicidal ideation (57.8%) and suicide attempts (2.6%) (Phillips & Menard, 2006 CIHR Author Manuscript CIHR Author Manuscript CIHR Author Manuscriptprevalence of the disorder in the general population appears to range between 0.7% and 2.4% (Faravelli, Salvatori, Galassi, & Aiazzi, 1997;Koran, Abujaoude, Large, & Serpe, 2008) but rates are much higher in certain groups such as students (2-13.1%) (Grant, Kim, & Crow, 2001;Mayville, Katz, Gipson, & Cabral, 1999) as well as in those presenting in dermatology (8.5-21.1%) and cosmetic surgery settings (2.9-16.6%) (Bellino etal., 2006;Bowe, Leyden, Crerand, Sarwer, & Margolis, 2007;Castle, Molton, Hoffman, Preston, & Phillips, 2004; Vulink et al., 2006).BDD is currently classified under somatoform disorders in DSM-IV-TR, but many experts conceptualize it as ...

DSM-5 Obsessive-Compulsive and Related Disorders: Clinical Implications of New Criteria

“…[35] BODY DYSMORPHIC DISORDER BDD has been included in the OCRDs chapter of DSM-5 due to similarities between BDD and OCD across many validators, including repetitive behaviors. [40,42] Moreover, BDD patients have been found to have an increased likelihood of being diagnosed with a psychotic disorder due to BDD or OCD-related delusional beliefs. [2] The core feature of BDD has remained unchanged, however-distressing or impairing preoccupation with perceived appearance defects or flaws that are not observable or appear slight to others.…”

“…[41] Probably the most clinically significant change to the diagnostic criteria of BDD is the inclusion of the delusional form of the disorder, noted by an insight specifier, "absent/delusional beliefs." [45] When insight is low or absent and OVI is high, techniques such as motivational interviewing [37] or inference-based therapy [42] may be helpful. [40,42] Moreover, BDD patients have been found to have an increased likelihood of being diagnosed with a psychotic disorder due to BDD or OCD-related delusional beliefs.…”

“…Clinical literature has suggested that BDD is characterized by poorer insight than OCD, [40] and that compared to OCD, patients with BDD have demonstrated greater overvalued ideas (OVI), a construct similar to poor insight. [40,42] Moreover, BDD patients have been found to have an increased likelihood of being diagnosed with a psychotic disorder due to BDD or OCD-related delusional beliefs. [43] Previously under DSM-IV, BDD individuals with delusional beliefs would have been classified as "delusional disorder, somatic type," in addition to BDD, accounting for approximately 36-39% of individuals with BDD.…”

“…A large proportion of BDD patients is considered to have little or no insight into their BDD symptoms; either that the perceived physical flaw is actually minimal (or does not exist) or that they may have a mental disorder. [45] When insight is low or absent and OVI is high, techniques such as motivational interviewing [37] or inference-based therapy [42] may be helpful.…”

Food for Thought: Change in Ego-Dystonicity and Fear of Self in Bulimia Nervosa Over the Course of Inference Based Treatment

“…Studies have demonstrated that IBT is equally effective in individuals with OVI and individuals without OVI [30][31][32]. IBT has been adapted to treat individuals with EDs [33].…”