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CBT's View of BDD
The use of cognitive behavior therapy for body dysmorphic disorder (BDD) is the only therapy proven through research to help BDD sufferers. The CBT approach assumes that people with BDD over-focus on small details of their appearance, and overemphasize physical appearance as a primary indicator of self-worth. Due to this, they downplay their own attractive aspects, while at the same time viewing the appearances of others as more positive than their own. All of these beliefs that people with BDD have can lead to anxiety or depression, sometimes causing them to resort to ritualistic behavior in order to alleviate their distress.
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Exposure Response Prevention (ERP)
There are three main techniques that CBT therapists use to treat BDD: exposure response prevention (ERP), cognitive restructuring, and mindfulness-based CBT. ERP is the primary technique used for BDD, in which people with the disorder are gradually put in situations that usually provoke rituals or avoidance behaviors. (ERP is also the primary CBT technique used for OCD.) They repeat the exposure to these situations again and again until their anxiety levels decrease due to habituation. ERP is used specifically to help people with BDD become more comfortable in social situations, as well as in front of mirrors. The therapist also teaches socially acceptable alternatives and coping behaviors that they can use instead of resorting to rituals or avoidance behaviors.
In circumstances when there is no specific situation that leads to the unwanted behaviors, or where the situation is constant (e.g., random anxiety over losing hair), the therapist can use a variation of ERP, called "imaginal exposure." To use this technique, people with BDD tell stories in which their worst fears turn out to be true - for example, they wake up and find that they are completely bald. These stories are taped and played over during the ERP process instead of actually recreating the anxiety-promoting situation, and typical ERP techniques are used to help people overcome their fears while listening to the recording.
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While ERP focuses on decreasing the actual behaviors that result from BDD, cognitive restructuring focuses on decreasing the negative thoughts and attitudes that people with BDD have about their bodies, or specific body parts. During cognitive restructuring, the therapist assists in identifying distorted beliefs that revolve around the body's appearance and replacing them with more positive, accurate beliefs. This process helps people with BDD understand how thoughts, feelings, and behaviors are interrelated, so that they can evaluate their unhealthy attitudes and replace them with healthier alternatives.
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The concept of mindfulness-based cognitive behavior therapy for body dysmorphic disorder is relatively new. It is based on the premise that anxiety and psychological discomfort result from trying to erase negative thoughts or obsessions from our minds. Therefore, it is not the thoughts or obsessions that are actually harmful, but the psychological damage caused by trying to control or eliminate them. Rather than removing these thoughts from consciousness therapists encourage people with BDD to become more comfortable with the fact that they experience them. The aim is to establish new relationships with these thinking patterns.
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