Edinburgh Therapy Service specialises in body dysmorphia therapy, delivering the gold standard treatment: cognitive-behavioural therapy with exposure and response prevention (CBT with ERP). Our therapy practice provides a secure and non-judgmental space where you can openly share your thoughts and concerns at a pace that aligns with your comfort. Let’s work together!
Body dysmorphic disorder (BDD) is a mental health condition where people experience persistent thoughts about one or more perceived defects or flaws in their appearance. The obsessions predominantly centre around the head and face (e.ghair, eyes, eyelids, nose, lips, mouth, jaw, chin, and skin), although any body part can be involved.
The focus is on perceived asymmetrical or disproportionate body features, thinning hair, acne, wrinkles, scars, vascular markings, as well as pallor or ruddiness of complexion. When reassured by others that they appear fine or that the perceived flaw is minimal, individuals with BDD struggle to accept or believe this reassurance.
As a result, this preoccupation can trigger feelings of embarrassment, self-consciousness, and anxiety, leading to avoidance of various social situations.
BDD has been suggested to be an OCD-spectrum disorder, and in some perspectives, it is viewed as a subtype of OCD. While these two conditions exhibit several shared features, the treatment approaches for OCD and BDD do have distinctions (Phillips et al., 2007).
Similar to OCD, people with BDD often engage in repetitive behaviours and rituals, such as frequent mirror-checking or seeking reassurance from others. They may also perform mental acts, like comparing one’s appearance with that of other people, as a response to their concerns about their appearance.
In an attempt to alleviate their distress, those with BDD may turn to various cosmetic procedures to fix the perceived flaw. While these interventions may provide temporary satisfaction or a momentary reduction in distress, the anxiety often resurfaces. This cycle may lead to continuously pursuing alternative ways to address the perceived flaw.
Cognitive-behavioural therapy (CBT) with exposure and response prevention (ERP) is a common approach in the treatment of body dysmorphic disorder.
Seeking help for body dysmorphic disorder is recommended when the symptoms interfere significantly with your daily life, relationships, and overall well-being. Here are some signs that indicate it might be time to find help:
➤ If the preoccupation with perceived flaws causes significant emotional distress and impairs your ability to function in everyday activities.
➤ When BDD affects your relationships, social interactions, or occupational functioning.
➤ If you find yourself avoiding social situations or isolating yourself due to concerns about your appearance.
➤ Engaging in excessive behaviours such as constant mirror-checking, seeking reassurance repeatedly, or spending excessive time on grooming rituals.
➤ If BDD contributes to feelings of depression, anxiety, or other mental health issues.
➤ If friends, family, or colleagues express concern about your preoccupation with appearance.
The therapies used for body dysmorphic disorder closely resemble those employed for OCD, and cognitive-behavioural therapy (CBT) with exposure and response prevention (ERP) has been identified as the most effective approach in successfully addressing it.
CBT models for BDD, as proposed by experts like Veale (2004) and Wilhelm et al. (2013), suggest that those with BDD tend to hyperfocus on minor details of their looks, rather than considering the overall picture. As a result, they often exaggerate the significance of perceived physical imperfections. This distorted perception leads to self-critical interpretations, contributing to negative emotions such as anxiety, shame, and sadness.
To alleviate these distressing feelings, people with BDD may engage in rituals, or avoidance strategies, such as withdrawing from social situations. While these rituals and avoidance behaviours may provide short-term relief, they reinforce maladaptive beliefs in the long-term, perpetuating negative thoughts about their look, and maintaining the circle of obsessions and compulsions in BDD.
CBT with ERP for BDD starts with an assessment and psychoeducation. Throughout this phase, the therapist gathers essential information to personalise the treatment plan according to the individual’s unique circumstances. Simultaneously, the therapist imparts insights into the CBT model of BDD and explains the rationale behind the chosen treatment approach.
CBT with ERP incorporates various techniques, including cognitive restructuring, exposure, ritual prevention, and relapse prevention, as integral components of the therapeutic process.
Cognitive restructuring
The aim of cognitive work for BDD is to identify maladaptive thoughts, evaluate them and generate alternative, more balanced perspectives. Several strategies contribute to this process, including raising awareness and actively challenging common cognitive errors frequently observed in BDD, such as “all-or-nothing thinking” (e.g., “My nose is extremely big”) or “mindreading” (e.g., “People will think this spot is disgusting”).
Exposure and response prevention (ERP)
ERP consists of two fundamental components. The first is exposure to the feared outcome and associated anxiety, while the second, response prevention, consists of refraining from performing the rituals or avoidance behaviours typically done to avert the feared outcome or alleviate anxiety.
In collaboration, the therapist and client construct a hierarchy of fears or avoided situations, systematically rating the distress level each situation would evoke for the client. For instance, someone with BDD might fear activities like changing in a dressing room, looking at mirrors, or going out without makeup. They may also avoid intimate encounters or entirely refrain from going out in public. Organising the hierarchy from less distressing elements to more challenging ones, the objective is to gradually approach these anxiety-inducing activities, starting with those causing low to medium distress and progressively advancing up the hierarchy.
Critical to the success of ERP is conducting exposures while preventing responses. This implies that the person refrains from executing any rituals or control strategies intended to diminish anxiety or distress during the exposure exercises.
Through systematic exposure to feared situations without resorting to rituals or avoidance behaviours, the person undergoes a process of habituation to anxiety. Over time, the intensity of the anxiety diminishes progressively. Simultaneously, this approach serves as a direct challenge to ingrained beliefs and fears, allowing the individual to firsthand test the actual outcomes in those situations they once feared.
We follow the recognized gold standard for treating BDD, utilising cognitive-behavioural therapy with exposure and response prevention (CBT with ERP), under the recommendations provided by NICE guidelines. Nevertheless, we acknowledge the uniqueness of each individual’s path to recovery. In certain cases, additional therapeutic methods such as acceptance and commitment therapy (ACT) or compassion-focused therapy (CFT) might offer valuable benefits. ACT and CFT can fulfil diverse roles in the treatment journey, potentially enhancing a client’s preparedness for CBT with ERP.
Additionally, we acknowledge that those with BDD may experience feelings of judgement. Therefore, it is of utmost importance to us to establish a secure and supportive environment, free from judgement. Our goal is to create an empathetic space where you can openly discuss intrusive thoughts without fear, ensuring you feel secure and understood.
BDD is characterised by persistent and distressing preoccupations with perceived flaws or defects in physical appearance. Common symptoms of BDD include:
Excessive self-focus: Intense and obsessive focus on perceived flaws in one’s appearance.
Distorted self-image: Seeing the perceived flaws as highly significant and noticeable, even when others may not observe them.
Repetitive behaviours: Engaging in repetitive behaviours or rituals to hide or fix perceived flaws, such as excessive grooming, seeking reassurance, or using makeup to cover perceived imperfections.
Avoidance: Avoiding situations or activities that trigger anxiety about appearance, leading to social isolation and impairment in daily functioning.
Comparison: Frequent comparison of one’s appearance with others.
Seeking cosmetic procedures: Repeatedly seeking cosmetic procedures or surgeries, even if they provide only temporary relief from distress.
While the precise causes of body dysmorphia remain unclear, certain factors have been identified that may impact its development and persistence. These include potential genetic predispositions, neurobiological differences in brain structure and functioning, societal and cultural pressures related to appearance, traumatic experiences during childhood or adolescence, psychological factors such as low self-esteem or a history of anxiety and depression, and the influence of media portraying idealised images of beauty. It’s important to note that these factors may interact in complex ways, and not everyone exposed to these influences will develop BDD.
The Edinburgh Therapy Service offers both in-person body dysmorphia counselling in Edinburgh (United Kingdom), and online therapy accessible worldwide. We specialise in therapy for BDD, offering CBT with ERP as the main treatment option.
Hello there! I’m Cristina, a therapist specialising in OCD, BDD, and related concerns. Having BDD can be disruptive, consuming considerable time and casting its impact across various facets of your life. It’s commonplace to experience overwhelming feelings, fear, or a sense of being adrift in the midst of these challenges. Additionally, there may be the added struggle of contending with the fear of judgement. I truly understand the hurdles related to this experience, and my commitment stands in providing steadfast support throughout your journey.
BDD counselling can be a demanding process, involving the confrontation of anxiety-inducing situations without resorting to compulsions. However, I will work at your own pace, breaking down these challenges into smaller, more manageable tasks. Remember, you’re not navigating this alone; I’ll be right there with you, guiding you through the process. Reach out, and let’s embark on this journey together!
The Edinburgh Therapy Service is a psychotherapy and counseling practice based in Edinburgh, Scotland (United Kingdom). We offer therapy both in-person in Edinburgh and online, available in English and Spanish.
Contact us for more information or to book your first appointment: [email protected]