“Is it really helpful for me to think that I can only be happy if my nose were straight?
”; Wilhelm et al., 2013), particularly for patients with poor insight.
Clinicians should be aware of clues in clinical presentation such as appearance (e.g., scarring due to skin picking) and behaviors (e.g, wearing camouflage), ideas or delusions of reference (e.g., feelings that people talk about them, stare at them), panic attacks (e.g., when looking into the mirror), depression, social anxiety, substance abuse and suicidal ideation as well as being housebound.
Additionally, differential diagnosis should be clarified in a structured clinical interview including eating disorders, obsessive compulsive disorder, depression, and social phobia.
The model proposes that individuals with BDD selectively attend to minor aspects of appearance as opposed to seeing the big picture.
This theory is informed by clinical observations and neuropsychological (Deckersbach et al., 2000) and neuroimaging findings (Feusner et al., 2007; Feusner et al., 2010).
Several studies have found CBT to successfully reduce BDD severity and related symptoms such as depression (Mc Kay, 1999; Mc Kay et al., 1997; Rosen et al., 1995; Veale et al., 1996; Wilhelm et al., 1999; Wilhelm et al., 2011; Wihelm et al., 2014).
CBT models of BDD (e.g., Veale, 2004; Wilhelm et al., 2013) incorporate biological, psychological, and sociocultural factors in the development and maintenance of BDD.
Individuals with BDD also overestimate the meaning and importance of perceived physical imperfections.
For example, when walking into a restaurant, a patient with BDD who has concerns about his nose might think, “Everyone in the restaurant is staring at my big, bulbous nose.” Patients are also more likely misinterpret minor flaws (e.g., perceived asymmetry) as major personal flaws (e.g., “If my nose is crooked, I am unlovable”) (Buhlmann et al., 2009; Veale, 2004).
These deeply held beliefs filter a patient’s experiences, and if not addressed, can thwart progress and long-term maintenance of gains.