Cognitive Behavioural Therapy (CBT)

If you feel that you are suffering from BDD, or have been diagnosed with BDD, the good news is that treatments are available. The best evidence so far supports two possible treatment options, which can be delivered independently of each other or can be given together. One treatment is psychological, Cognitive Behavioural Therapy (CBT), and the other option is medication.

What is CBT?

Cognitive Behavioural Therapy (CBT) is based on a structured programme of self-help so that a person can learn to change the way they think and act.

“Cognitive” refers to the events that take place in your mind (thoughts, images, memories, or processes like ruminating and worry). “Behaviour” is what you do (for example escape, avoid, check).

CBT starts with building a good understanding of the problem and what is keeping it going in terms of how your mind works.  Very often it turns out that ‘the solution is the problem’. For example, you might examine your appearance in the mirror to try and work out ‘how do I really look?’ but rather than leaving you feeling more certain of how you look, it might leave you feeling less certain and more preoccupied.

One way of thinking about BDD is that it is a problem of ‘not being able to see the wood for the trees’ – that you can no longer make an objective assessment of your appearance because you have become so distressed and preoccupied. Because you are excessively self-focused on your felt impression, you assume that this is how others view you. This often leads to radically different opinions on your appearance between yourself and those who are close to you.

Being self-focused through scrutinising and monitoring your appearance, or the reactions of others, can increase feelings of self-consciousness and make being out in social situations very uncomfortable.

During therapy, you are likely to learn to re-focus your attention away from your self and re-engage with activities that will improve your mood and your life.  Many people come to view their negative self-image of their looks as a bad memory from the past, such as bullying or teasing. To help reduce self-consciousness a CBT therapist might recommend specific attention-training exercises.

To further fight back you will be asked to resist comparing your appearance, to stop ruminating, test out your fears without camouflage and stop rituals such as checking and excessive grooming. Many people find it helpful to think of CBT for BDD as training in how to stop being bullied by their BDD and to re-direct themselves into all the other aspects of living that are important to them.

The main side effects of the treatment are the anxiety that occurs in the short term. However, testing one’s fear gets easier and easier and the anxiety gradually subsides.

The principles of CBT for BDD are described in various books. Below is a description of how to get therapy in the UK.

Good CBT for BDD is likely to involve the following:

• A shared understanding of your main problems and goals
• A ‘formulation’ – a diagram or verbal explanation of how your BDD developed and how it is being maintained that will be tested out in therapy
• Sessions focused largely upon your BDD
• Tasks within the session for example testing some of your fears
• Agreed ‘homework’ tasks to be completed outside the sessions, and reviewed at the next session
• The understanding of your CBT therapist and genuine care that you improve
• A strong focus upon you re-claiming your life, facing feared/avoided situations, and reducing the repetitive behaviours (e.g. comparing, checking, reassurance seeking, camouflaging and concealing)
• A clear focus upon reducing your preoccupation and distress, and improving function. Body image in BDD usually only returns to normal once the person’s preoccupation and distress have reduced and functioning has improved.

Good CBT would generally NOT include:

• Reassuring you about your appearance or entering into extensive debates about how you look or whether appearance is important
• Teaching you phrases about your appearance to tell yourself
• Long discussions about childhood, unless they relate to experiences clearly connected to the development of your BDD and lead to exercises that help to update the ghosts from the past so they are not relevant for your life now
• Homework tasks that are not explained and negotiated or that do not seem linked to your BDD.

So the first step is to ask the therapist what type of therapy they are planning to use. If it is not CBT, beware, as there is little evidence to support other types of psychotherapy for BDD.

Questions to ask a therapist

• Have you been to specific workshops or had training on treating BDD?
• Do you follow a recognized protocol on treating BDD?
• Do you keep up to date and attend conferences?
• How often do you treat BDD? How many people with BDD have you treated?
• Do you have supervision, and how?
• Are you accredited in CBT (in the UK by BABCP) – this is not crucial but is common in the private sector to demonstrate a minimum standard of training, supervision and continuing professional development.

Other things to consider

• Do you feel the therapist is someone you can trust, who respects you?
• Do you think your therapist can support you – like a good teacher or coach?
• Do you feel well understood by the therapist? You should feel your views are sought and you are involved in the process.
• Do you find the therapist encouraging and positive about your ability to make improvements (especially in the moment), seeing problems as a way of learning better ways of dealing with the BDD? The therapist should be challenging and have high expectations about your ability to change.
• Ask how other people referred to the service for their BDD have got on.
• A good therapist keeps a record of outcome session by session, for example by using a questionnaire or rating scale that is specific for BDD to monitor progress (see examples on this website)
• Your sessions should focus on BDD most of the time unless there are more pressing problems interfering with your progress.

We have a selection of helpful videos on CBT Therapy: