Hostname: page-component-586b7cd67f-t8hqh Total loading time: 0 Render date: 2024-11-29T19:01:34.784Z Has data issue: false hasContentIssue false
  • English
  • Français

‘If you have good skin, you are god. If you have bad skin, you are a piece of rubbish’. Mastery of shame and anger in treatment-resistant body dysmorphic disorder: a single case study

Published online by Cambridge University Press:  29 July 2016

Oliver Sündermann ,
Jonathan Wheatley  and
David Veale Open the ORCID record for David Veale [Opens in a new window]
Oliver Sündermann*
Affiliation:
The Priory North London, Obsessional Disorders Department, London, UK Department of Psychology, National University of Singapore, Singapore
Jonathan Wheatley
Affiliation:
Primary Care Psychology, St Leonards Hospital, London, UK
David Veale
Affiliation:
The Institute of Psychiatry, Psychology and Neurosciences, King's College London, London, UK The Anxiety Disorders Residential Unit, Dower House, The Bethlem Royal Hospital, Beckenham, Kent, UK
*
*Author for correspondence: Dr O. Sündermann, Department of Psychology, National University of Singapore, 02–24, 9 Arts Link, 117570Singapore (email: [email protected]).
Get access Rights & Permissions [Opens in a new window]

Abstract

Body dysmorphic disorder (BDD) is characterized by a preoccupation with a perceived flaw in one's appearance, and is often emotionally linked with early adverse experiences. Cognitive behavioural therapy (CBT) is effective but may not resolve shame and anger that can be at the emotional root of BDD. This paper presents a single-case study of a 25-year-old man with a history of treatment-resistant BDD characterized by a preoccupation with facial skin linked to a developmental history of sexual abuse and bullying. He was treated at a national residential specialist unit for 16 weeks during which time he received three individual 1-hour weekly CBT sessions (42 sessions overall), and participated in the residential group programme and therapeutic community. CBT was enhanced using imagery rescripting, compassion-focused therapy and family work to specifically target shame and anger-based past experiences. Severity of BDD was assessed with the BDD-Yale–Brown Obsessive Compulsive Scale (BDD-YBOCS) at pre-, mid-, post-, 3-month and 18-month follow-ups; a weekly self-report measure (Appearance Anxiety Inventory), and a client-drawn self-portrait of his perceived skin flaws at pre- and post-treatment. Treatment outcome was positive. The BDD-YBOCS dropped 94% from the extremely severe range pre-treatment to the sub-clinical range post-treatment. BDD symptoms improved progressively throughout treatment, and when the emotions of anger and shame were resolved (as reported by the client) fell to the non-clinical range. Gains were maintained at 18-month follow-up. We conclude that enhancing CBT for BDD using emotion-focused techniques is to be recommended, particularly when emotional memories continue to affect body shame.

Keywords

AngerBDDcompassionimagery rescriptingshame
Type
Practice article
Information
the Cognitive Behaviour Therapist , Volume 9 , 2016 , e13
Copyright
Copyright © British Association for Behavioural and Cognitive Psychotherapies 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Recommended follow-up reading

Phillips, KA (2005). The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder. New York, NY: Oxford University Press.Google Scholar
Veale, D, Gilbert, P (2014). Body dysmorphic disorder: the functional and evolutionary context in phenomenology and a compassionate mind. Journal of Obsessive-Compulsive and Related Disorders 3, 150–160.Google Scholar
Veale, D, Gilbert, P, Wheatley, J, Naismith, I (2014). A new therapeutic community: development of a compassion-focussed and contextual behavioural environment. Clinical Psychology & Psychotherapy 22, 285–303.Google Scholar
Veale, D, Neziroglu, F (2010). Body Dysmorphic Disorder: A Treatment Manual. John Wiley & Sons.Google Scholar
Wilhelm, S, Phillips, KA, Steketee, G (2012). Cognitive-behavioral Therapy for Body Dysmorphic Disorder: a Treatment Manual. New York: Guilford Press.Google Scholar

References

Arntz, A, Weertman, A (1999). Treatment of childhood memories: theory and practice. Behaviour Research and Therapy 37, 715–740.Google Scholar
Boroughs, MS, Krawczyk, R, Thompson, JK (2010). Body dysmorphic disorder among diverse racial/ethnic and sexual orientation groups: prevalence estimates and associated factors. Sex Roles 63, 725–737.CrossRefGoogle Scholar
Buhlmann, U, Marques, LM, Wilhelm, S (2012). Traumatic experiences in individuals with body dysmorphic disorder. Journal of Nervous and Mental Disease 200, 95–98.Google Scholar
Cassiello-Robbins, C, Barlow, DH (2016). Anger: the unrecognized emotion in emotional disorders. Clinical Psychology: Science and Practice 23, 66–85.Google Scholar
Craske, MG, Treanor, M, Conway, CC, Zbozinek, T, Vervliet, B (2014). Maximizing exposure therapy: an inhibitory learning approach. Behaviour Research and Therapy 58, 10–23.Google Scholar
Didie, ER, Tortolani, CC, Pope, CG, Menard, W, Fay, C, Phillips, KA (2006). Childhood abuse and neglect in body dysmorphic disorder. Child Abuse & Neglect 30, 1105–1115.Google Scholar
Drummond, LM, Fineberg, NA, Heyman, I, Kolb, PJ, Pillay, A, Rani, S, Salkovskis, P, Veale, D (2008). National service for adolescents and adults with severe obsessive-compulsive and body dysmorphic disorders. The Psychiatrist 32, 333–336.Google Scholar
Ehlers, A, Clark, DM (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy 38, 319–345.CrossRefGoogle ScholarPubMed
First, MB, Spitzer, RL, Gibbon, M, Williams, JBW (1997). Structured Clinical Interview for DSM-IV Axis 1 Disorders – Non-patient edition (version 2.0). New York: New York State Psychiatric Institute, Biometrics Research Department.Google Scholar
Geremia, GM, Neziroglu, F (2001). Cognitive therapy in the treatment of body dysmorphic disorder. Clinical Psychology & Psychotherapy 8, 243–251.Google Scholar
Gilbert, P, Miles, J (2002). Body Shame: Conceptualization, Research, and Treatment. New York: Brunner-Routledge.Google Scholar
Gunstad, J, Phillips, KA (2003). Axis I comorbidity in body dysmorphic disorder. Comprehensive Psychiatry 44, 270–276.CrossRefGoogle ScholarPubMed
Kroenke, K, Spitzer, RL (2002). The PHQ-9: a new depression diagnostic and severity measure. Psychiatric Annals 32, 1–7.Google Scholar
LeBeau, RT, Mischel, ER, Simpson, HB, Mataix-Cols, D, Phillips, KA, Stein, DJ, Craske, MG (2013). Preliminary assessment of obsessive–compulsive spectrum disorder scales for DSM-5. Journal of Obsessive-Compulsive and Related Disorders 2, 114–118.Google Scholar
Lobbestael, J, Leurgans, M, Arntz, A (2011). Inter-rater reliability of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID I) and Axis II Disorders (SCID II). Clinical Psychology and Psychotherapy 18, 75–79.Google Scholar
McKay, D, Todaro, J, Neziroglu, F, Campisi, T, Moritz, EK, Yaryura-Tobias, JA (1997). Body dysmorphic disorder: a preliminary evaluation of treatment and maintenance using exposure with response prevention. Behaviour Research and Therapy 35, 67–70.Google Scholar
Morley, S, Dowzer, CN (2014). Manual for the Leeds Reliable Change Indicator: simple Excel™ applications for the analysis of individual patient and group data. Leeds, UK: University of Leeds.Google Scholar
Neziroglu, F, Khemlani-Patel, S, Veale, D (2008). Social learning theory and cognitive behavioral models of body dysmorphic disorder. Body Image 5, 28–38.Google Scholar
Neziroglu, F, Khemlani-Patel, S, Yaryura-Tobias, JA (2006). Rates of abuse in body dysmorphic disorder and obsessive-compulsive disorder. Body Image 3, 189–193.CrossRefGoogle ScholarPubMed
Neziroglu, F, McKay, D, Todaro, J, Yaryura-Tobias, JA (1996). Effect of cognitive behavior therapy on persons with body dysmorphic disorder and comorbid axis II diagnoses. Behavior Therapy 27, 67–77.Google Scholar
Osman, S, Cooper, M, Hackmann, A, Veale, D (2004). Spontaneously occurring images and early memories in people with body dysmorphic disorder. Memory 12, 428–436.Google Scholar
Phillips, KA, Hart, AS, Menard, W (2014). Psychometric evaluation of the Yale–Brown Obsessive-Compulsive Scale modified for body dysmorphic disorder (BDD-YBOCS). Journal of Obsessive-Compulsive and Related Disorders 3, 205–208.CrossRefGoogle Scholar
Phillips, KA, Hollander, E, Rasmussen, SA, Aronowitz, BR, DeCaria, C, Goodman, WK (1997). A severity rating scale for body dysmorphic disorder: development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacology Bulletin 33, 17.Google Scholar
Rief, W, Buhlmann, U, Wilhelm, S, Borkenhagen, ADA, Brähler, E (2006). The prevalence of body dysmorphic disorder: a population-based survey. Psychological Medicine 36, 877–885.Google Scholar
Ritter, V, Stangier, U (2016). Seeing in the Mind's eye: imagery rescripting for patients with body dysmorphic disorder. A single case series. Journal of Behavior Therapy and Experimental Psychiatry 50, 187–195.Google Scholar
Rosen, JC, Reiter, J, Orosan, P (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology 63, 263–269.Google Scholar
Spitzer, RL, Kroenke, K, Williams, JB, Löwe, B (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine 166, 1092–1097.Google Scholar
Storch, EA, Bagner, D, Merlo, LJ, Shapira, NA, Geffken, GR, Murphy, TK, Goodman, WK (2007). Florida obsessive-compulsive inventory: Development, reliability, and validity. Journal of Clinical Psychology 63, 851–859.Google Scholar
Veale, D (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image 1, 113–125.Google Scholar
Veale, D, Anson, M, Miles, S, Pieta, M, Costa, A, Ellison, N (2014 a). Efficacy of cognitive behaviour therapy versus anxiety management for body dysmorphic disorder: a randomised controlled trial. Psychotherapy and Psychosomatics 83, 341–353.Google Scholar
Veale, D, Boocock, A, Gournay, K, Dryden, W, Shah, F, Willson, R, Walburn, J. (1996). Body dysmorphic disorder. A survey of fifty cases. British Journal of Psychiatry 169, 196–201.Google Scholar
Veale, D, Eshkevari, E, Kanakam, N, Ellison, N, Costa, A, Werner, T (2014 b). The Appearance Anxiety Inventory: validation of a process measure in the treatment of body dysmorphic disorder. Behavioural and Cognitive Psychotherapy 42, 605–616.Google Scholar
Veale, D, Gilbert, P (2014). Body dysmorphic disorder: the functional and evolutionary context in phenomenology and a compassionate mind. Journal of Obsessive-Compulsive and Related Disorders 3, 150–160.Google Scholar
Veale, D, Gilbert, P, Wheatley, J, Naismith, I (2014 c). A new therapeutic community: development of a compassion-focussed and contextual behavioural environment. Clinical Psychology & Psychotherapy 22, 285–303.Google Scholar
Veale, D, Gournay, K, Dryden, W, Boocock, A, Shah, F, Willson, R, Walburn, J (1996). Body dysmorphic disorder: a cognitive behavioural model and pilot randomised controlled trial. Behaviour Research and Therapy 34, 717–729.Google Scholar
Veale, D, Neziroglu, F (2010). Body Dysmorphic Disorder: A Treatment Manual. John Wiley & Sons.CrossRefGoogle Scholar
Weingarden, H, Renshaw, KD (2015). Shame in the obsessive compulsive related disorders: a conceptual review. Journal of Affective Disorders 171, 74–84.Google Scholar
Whiting, D, Bryant, DRA (2007). Role of appraisals in expressed anger after trauma. Clinical Psychologist 11, 33–36.Google Scholar
Wilhelm, S, Otto, MW, Lohr, B, Deckersbach, T (1999). Cognitive behavior group therapy for body dysmorphic disorder: a case series. Behaviour Research and Therapy 37, 71–75.CrossRefGoogle ScholarPubMed
Wilhelm, S, Phillips, KA, Didie, E, Buhlmann, U, Greenberg, JL, Fama, JM, Keshaviah, A, Steketee, G (2014). Modular cognitive-behavioral therapy for body dysmorphic disorder: a randomized controlled trial. Behavior Therapy 45, 314–327.Google Scholar
Willson, R, Veale, D, Freeston, M (2016). Imagery rescripting for body dysmorphic disorder: a multiple-baseline single-case experimental design. Behavior Therapy 47, 248–261.Google Scholar
Submit a response

Comments

No Comments have been published for this article.