Jessica is a sixteen-year-old teenager who is overly concerned about the size of her head. She believes that her head is larger than the average individual’s head. Jessica goes out of her way to camouflage the size of her head, by wearing her hair down and wearing glasses. When in public she is convinced that others are staring at her head and reacting with disgust. As a result of her preoccupation and the distress it causes, she avoids school and socializing and prefers to spend her days in her room.
Dave is a man in his mid 30’s who is overly concerned about his hair. He spends hours in the mirror making sure his hair is symmetrical on both sides. He spends most of his money on haircuts which are never satisfactory to his liking. After fixing his hair himself and by professionals, Dave eventually shaves his head and falls into a deep depression. He refuses to leave his home or to be seen by others. Occasionally, he agrees to be around others with a hat but will be hesitant to leave the house.
Jessica and Dave suffer from Body Dysmorphic Disorder (BDD). This is a preoccupation with an imagined or slight defect in appearance. This perceived defect is often unnoticeable to others or minor enough where it would not elicit excessive concern in most people. Individuals suffering from BDD are severely distressed by their perceived flaws and describe their preoccupations as “painful, tormenting and difficult to control”. Concern over physical appearance compels BDD sufferers to think about their appearance for many hours a day. Preoccupation with the perceived defect is exhibited by spending numerous hours in front of a mirror. During mirror gazing, individuals attempt to camouflage their perceived flaw with make-up, hair, body position or clothing. Others engage in excessive grooming behaviors such as combing, cutting or styling hair. Some pick at their skin in order to remove blemishes. On the other hand some individuals will avoid mirrors at all costs to prevent from viewing their perceived flaw. Additionally, these individuals might ask for reassurance related to the imagined defect. Usually the individual is concerned with a particular feature such as their head, however, the preoccupation can be a more broad idea such as being ugly.
Cognitive-behavior therapy is the first line of treatment for BDD. This type of treatment typically involves a technique known as exposure and response prevention. Exposure therapy identifies the cognitions, emotions and physiological arousal that accompany a fear-inducing stimulus. This technique attempts to break the pattern of escape that strengthens the fear response through measured exposure to progressively stronger stimuli until habituation is reached. In the case of BDD, exposure is aimed to decrease compulsive behaviors such as mirror checking and camouflaging. Poor prognosis variables such as high overvalued ideation (system of dysfunctional beliefs that are held strongly, and have a strong affective component when contradictory information is presented), suicidality and depression also influence a poor response to CBT. For these reasons, it is useful to consider incorporation of a different approach in conjunction with CBT to allow for adherence.
Acceptance and commitment therapy (ACT) is an example of such a treatment. Acceptance and commitment therapy is divided into three core concepts: 1) acceptance 2) mindfulness and 3) value based living. Acceptance entails allowing inner experiences to occur without taking steps to regulate or control them. Dave will learn to accept his obsession without engaging in time consuming compulsions to avoid them. Mindfulness refers to developing the ability to being present in the moment and being able to observe without making judgments. For example, Jessica will learn how to observe her appearance without making the conclusions that she is hideous. While Dave will learn how to be present in the moment instead of having all of his thoughts center on his hair. Lastly, the third component of ACT involves living a value based life which refers to living your life according to your own values and not symptoms. For Jessica this means living life based on her values such as being loved and family instead of acting on her feelings of depression and anxiety related to her appearance. For Dave this may mean living for a prosperous career and for his children and not acting on his feelings of despair and loneliness associated to his appearance.
In summary, ACT treatment goals include living a meaningful existence, living according to patient’s values, focusing on the present moment, and tolerating emotions. The inclusion of ACT with CBT serves to increase the palatability and motivation to engage in treatment for resistant BDD.
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