CBT vs. Psychoanalytic therapy on Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) also referred to as a dysmorphic disorder, is a psychological disorder characterized by minor defects or excessive preoccupation of the face or any other localized part of the body. The condition has to be severe for it to affect a person's occupation, studies or social life. Individuals affected by this condition spend a considerable amount of time looking at themselves in the mirror, having a perception of distorted images of their body parts like a crooked nose, uneven smile, small or very large eyes, etc. They spend hours, worried about their looks and some even contemplate suicide. The prevalence of BDD has led to a significant increase in cosmetic surgeries and repeated surgeries in some cases. BDD patients also portray low self-esteem, have problems in socializing, and they even have problems coping with their studies and careers. BDD can be treated using two therapies, Cognitive behavioral therapy (CBT) and the Psychoanalytic application. The Cognitive behavioral therapy (CBT), states that individuals with BDD attend selectively to the minor details of their looks, have problems in socialization, develop negative emotions resulting from their perceived flaws and they neutralize aversive behaviors with ritualistic behaviors, e.g. mirror checking.CBT seeks to replace negative thought patterns with positive thoughts. On the other hand, the Psychoanalytic theory treats mental disorders by critically analyzing the interaction between the conscious and unconscious domains of a patient's mind. This paper seeks to describe the Body dysmorphic disorder (BDD), highlight the population affected by the disease, compare the effectiveness of CBT and the Psychoanalytic application towards the treatment of BDD. 

No one knows the cause of Body dysmorphic disorder (de Brito et al.,2016). The disorder that begins at teenage age or adolescence stage is believed to have several causal elements which consist of; environmental, biological and psychological factors. Bullying, teasing, and ridicule, for example, may create a feeling of shame and inadequacy within an individual.BDD affects males and females in equal measure. 

Symptoms of the Body dysmorphic disorder 

According to Hollander et al. (2016), people living with the condition show several symptoms. To begin with, these patients are significantly affected with a perceived imperfection which other people cannot see. They also have a strong belief in having a defect that makes them look ugly. These patients also engage in behaviors that help them to hide their perceived imperfections. Others will avoid social situations. They become obsessed with any part of the body, they also develop an interest in mirrors, and some avoid mirrors completely, seeking surgery, skin picking, changing clothes excessively, excessive grooming, others hide their body parts in scarfs, hats or by doing makeup, constantly making comparisons of themselves with other and they are always asking others to tell them if they look good. We can find that the condition can negatively dent an individual's self-esteem. 

Prevalence of the Body Dysmorphic Disorder 

For a long time, BDD was on a more significant part underdiagnosed and thought to be a rare case. Scientific research had not identified many symptoms of BBD (Harrison et al.,2016). It was also hard to ascertain the population of BDD patients as many of them were reluctant to reveal their condition to their family members and therapists for fear of being embarrassed. In recent times, prevalence studies of BDD together with the identification of the clinical features of the condition has revealed that many people in the society are affected by the Body dysmorphic disorder. 

Studies have revealed that BDD affects both men and women irrespective of their socioeconomic classes; about 40% of the affected population are males while 60% are women (Phillips,2015).To add on that, the disorder also affects people of all ages, beginning at the age of 4-5 years onwards, but most cases are reported to have started at the age of 12 to 13 years. It is a stage where the youth are experiencing body changes, and they become conscious about their looks. It is also critical to note that about two-thirds of people living with BDD experienced its onset before the age of 18 years. The condition also affects people of all races and ethnicity as patients have been diagnosed with the condition in South America, North America, Asia, Europe, Australia, and even Africa. According to all these revelations, anyone can get the Body dysmorphic disorder. 

Body Dysmorphic Disorder affects about 1.7-2.4% of the population. About one person in a group of fifty in affected by BDD. These estimates show that approximately 5-7 million people in the US alone have this condition. BDD is more common than even other disorders that are considered common such as the Social anxiety disorder and the obsessive-compulsive disorder (Veale et al.,2016). It is even more common than conditions such as schizophrenia and anorexia nervosa. Individuals living with BDD might also be more since many of them are reluctant in revealing their status to others. The disorder has affected a significant population as health care centers are registering a substantial population of people who come to seek cosmetic surgeries, cosmetic dental services, and adult orthodontia services. 

Treatment of the Body Dysmorphic Disorder 

Many people with this disorder believe that defects cause their condition on their physic. They seek dermatological procedures, dental treatment together with cosmetic surgery but surprisingly enough, these interventions rarely work but only worsens the situation. Body dysmorphic disorder is treated using Cognitive behavioral therapy and the Psychoanalytic theory (Phillips,2015). 

Cognitive Behavioural Theory 

To begin with, CBT models incorporate the psychological, social and biological factors when treating and managing the Body dysmorphic disorder (Veale et al.,2016). To add on, this model also includes cognitive restructuring, exposure technique, ritual prevention and finally, relapse prevention. In some cases, CBT may also include mirror retraining (Veale et al.,2016). This treatment model alleges that individuals are living with BDD attent to minor aspects of their appearance selectively. Patients with this condition also have a problem of overestimating the meaning and their perceived imperfections (Veale et al.,2016). For example, when walking into a public place, a patient with this condition having concerns with her nose might have a feeling that everyone at that place is gazing at her big or deformed nose (Mancusi et al.,2017). These self-defeating feelings caused by misinterpreting minor flaws might lead to negative emotions such as shame, anxiety, and sadness (Veale et al.,2016). Patients attempt to neutralize these feelings by seeking surgery, avoiding social situations or excessively gazing at the mirror (Mancusi et al.,2017). 

Assessment, psychoeducation, and motivational assessment 

The first step in the treatment of BDD utilizing CBT is psychoeducation and assessment (Phillips et al., 2015). Therapists evaluate the associated symptoms that consist of behaviors, thought and impairments. Motivational techniques should be used when dealing with patients exhibiting delusional appearance beliefs and also those who reluctant in accepting CBT interventions (Phillips et al., 2015). During this stage, a therapist will create an individualize CBT model for the BDD patient.BDD treatment using CBT highly depends on behaviors and thought patterns that maintain the disorder as an essential aspect for change (Phillips et al., 2015). For this reason, a therapist describes the cognitive aspect of the behavior and provides more general information showcasing the significance of physical appearance in the daily life of the patient (Phillips et al., 2015). 

The next step is that the clinician will facilitate the patient with psychoeducation, such as common symptoms, prevalence, and the existing differences images and their real appearance (Sarwer,2016). The therapist is then required to formulate an individualized model that befits his patient's unique symptoms. This model encompasses theories explaining how the sociocultural, psychological and biological body images develop (Veale et al.,2016). For a therapist to come up with a useful treatment module, he investigates his patient’s triggers for negative beliefs, emotional reactions of the patient towards negative thoughts and coping strategies used by BDD patients. 

Subsequently, this treatment plan also utilizes techniques such as exposure, self-monitoring cognitive reconstruction, response prevention, and lapse prevention (Veale et al.,2016). Patients are encouraged to record their thought patterns and behaviors affecting them. They are also required to give an account of the duration and frequency of the problematic behaviors and thoughts targeted to initiate change (Veale et al.,2016). Self-monitoring also helps the patients to monitor their progress throughout the treatment period. They measure progress by observing the reduction of time they spend on problematic behaviors (Veale et al.,2016). 

Cognitive restructuring 

Cognitive restructuring involves the identification of maladaptive behaviors and thoughts relating to their appearance and then challenging them (Mancusi et al.,2017). Therapists encourage patients to conceptualize the fact that a person has many characteristics apart from just the physical appearance (Mancusi et al.,2017). Therapists assign patients with behavioral experiments aimed at disapproving their assumptions about ugliness and defectiveness by consolidating pieces of evidence that are against their beliefs (Mancusi et al.,2017). 

Exposure and ritual prevention 

At this stage, the patient together with the therapist develops a hierarchy of avoided and anxiety-provoking situations (Mancusi et al.,2017). The hierarchy includes conditions that will improve the social experiences of patients. For instance, a patient will be encouraged to hang out with friends instead of avoiding them (Mancusi et al.,2017). Patients should be encouraged to monitor rituals by checking on the contexts and frequencies at which they arise. The patients are then taught on how to eliminate rituals by resisting them (Mancusi et al.,2017). 

Perpetual Training 

BDD patients have been affected by mirrors and other reflective surfaces. These patients will spend hours stuck in the mirror while grooming or others will completely avoid mirrors (Thompson,2014). At this stage, patients are trained to have an objective view of themselves through the mirror. They are encouraged to refrain from habits such as zoning or touching specific body parts. Perpetual training also helps patients to focus on other aspects of the environment other than their appearance. 

Relapse Prevention 

At the last stages, BDD treatment utilizing CBT is aimed at preventing the reoccurrence of unwanted traits Hollander et al.,2016). At this stage, patients are taught how to manage the upcoming challenges in their future lives (Hollander et al.,2016). Therapists encourage patients to pinpoint the triggers and potential pitfalls that may cause a relapse. For instance, unexpected comments from co-workers and also upcoming events are ingredients that may trigger a relapse (Hollander et al.,2016). Patients who go through the process successfully often return for additional therapy, especially after noticing the return of BDD symptoms (Hollander et al.,2016). 

Though practiced on a small group of individuals, case studies have indicated a significant improvement of BDD symptoms after the treatment (Hollander et al.,2016). Two randomized controlled studies were done on 54 BDD patients; the first group consisting of patients who did not receive any treatment and the other constituting patients receiving CBT treatment reveals that 82% of patients under CBT treatment were rehabilitated while the later recorded no change. The rehabilitated patients portrayed a significant improvement in their psychological functioning, body dissatisfaction, appearance preoccupation as well as high self-esteem. 

The Psychoanalytic Approach 

The Psychoanalytic theory examines the formation of body images and consequently gives insight on how those images are distorted in BDD. Apart from suggesting the causes of distortion of these images, the theory also helps in managing the problematic beliefs experienced by patients (Hollander et al.,2016). According to this theory, understanding the unconscious processes is critical in finding the causes of distortion. To begin with, according to the psychoanalytic theory, the Body Dysmorphia is a neurotic symptom. According to Freud, neurotic symptoms are "acts detrimental."Basing on this argument, BDD patients exhibit severe levels of fear and anxiety which makes them be in a state of denial and in some cases it even leads to suicide. 

The Psychoanalytic theory views the self as being an aesthetic object. It refers to the experiences of self-focused attention and extreme self-consciousness as a distorted image. Furthermore, the theory argues that mental images are contained in a person's consciousness, and they possess intellectual or verbal sensory qualities (Mancusi et al.,2017). To that effect, distorted mental images experienced by BDD patients are internal distortions of visual representations existing in their minds. Sigmund Freud, a proponent of this theory, argues that distorted images are activated by the external description of a person's appearance, for instance, when individuals look in mirrors. 

Self-focused attention and imagery are significant in treating Body dysmorphic disorder. The understanding of imagery and how it links with early experiences together with the meaning of that image serves as a reference point of engagement. An "image" is constructed as a problem, rather than the appearance of an individual (Wilhelm et al.,2015). This will help BDD patients to understand that perception is not always accurate. It is therefore imperative to conclude that negative self-beliefs cannot be accessed on the physic but through the images formed in mind. 

Conclusion  

Basing on the two approaches used in treating BDD, CBT is the most preferred. When using the CBT approach, BDD patients are actively involved in all stages of treatment, for example, the patient together with his therapist identifies triggers for negative beliefs and then develops a model of managing the problem. On the other hand, the Psychoanalytic theory largely depends on abstract formulations in which the patient is not actively involved. 

Secondly, Contrary to the Psychoanalytic theory, the Cognitive-behavioral approach has earned reviews as an appropriate plan for treating CBT. The theory's strength in altering behaviors and thoughts, its effectiveness in treating patients who could not respond to medication has made it outstanding. Something important to note about this theory is that it is completed in a relatively short period compared to the Psychoanalytic theory.CBT is highly recommended because patients are equipped with practical, useful skills that they incorporate in their daily life to manage future difficulties and stress even after the completion of treatment. 

References  

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