Engagement key in cognitive behavioral therapy for patients with body dysmorphic disorder

DENVER – Successful cognitive behavioral therapy for body dysmorphic disorder must be mindful of patient engagement and assessment, according to a presentation at the Anxiety and Depression Association of America annual conference.

“The DSM-5 when it was published, acknowledged BDD and OCD as related conditions and put it all into one category. Since then, there’s been a lot more recognition and appropriate assessment of the disorder,” Sony Khemlani-Patel, PhD, of the Bio Behavioral Institute, said during the presentation.

“Unfortunately, we still see people who come to our clinic today misdiagnosed often.”

With the new classification of BDD under OCD spectrum disorders, root causes in behavior rooted within perceptions of defects in physical appearance need to be uncovered, utilizing differential diagnoses, to address certain preoccupations associated with safety behaviors, Khemlani-Patel said.

These behaviors, such as continual mirror gazing, camouflaging, ruminating, picking of exposed skin, intense comparison to friends and others in social situations, as well as desire for needless dermatological or cosmetic corrections, require multiple strategies to work through for both patient and therapist.

Khemlani-Patel said part of the good-faith effort within patient engagement to address these issues is dependent upon safety and flexibility in one’s treatment approach. She cited several situations where meeting the patient on their terms aided treatment — the patient had their camera turned off during a video session; the patient was met in a secluded parking lot; and another instance where an in-office session was conducted in the dark.

Gains have been made in treatment and recognition of BDD through image rescripting, attentional training, instruction on reversing negative habits, as well as exposure and response prevention techniques, Khemlani-Patel said.

Khemlani-Patel also said that teletherapy has produced a whole new subset of positives and negatives associated with the therapeutic process in BDD.

“For people who don’t like to leave their house, teletherapy has been really wonderful. A parent can just turn on the [video call] and maybe turn the camera off at least for that first [patient] conversation,” she noted.

Khemlani-Patel’s co-presenter, Fugen Neziroglu, MD, acknowledged several types of inappropriate treatment courses — chief among them were recommendations for cosmetic surgery and psychoanalysis.

“Because [they] just make the person more obsessional and more preoccupied,” Neziroglu said.

Identification through recognition of the therapists’ own body issues should also be avoided, as it may be considered by the patient as an admission that their own particular perceived flaw is observable.

“The struggle in BDD is in the activation. Going out in public and doing things. And if they’re not, because of their BDD, it’s a difficult impasse as well,” Khemlani-Patel said. “So if you can create any type of situation where the patient feels safe, they can get out and start to feel better.”