Behavioral therapy for dysmorphophobia

Psychotherapy for body dysmorphic disorder

Who would describe themselves as flawlessly attractive? Who could claim to be completely without blemishes? Most women and men have more or less complaints about their external appearance and are constantly striving to optimize it. The pursuit of a perfect shell is understandable insofar as physical attractiveness is associated with numerous positive characteristics in our society. For example, pretty people are considered to have greater intelligence, social skills, etc., which opens up more opportunities for them both professionally and privately. However, when the preoccupation with one's own appearance occupies the entire mind, we speak of body dysmorphic disorder.

JUVENIS consultation room for psychotherapy for body dysmorphic disorder

Treatments & therapies

Psychotherapy for body dysmorphic disorder

However, if this preoccupation with one's own appearance described above becomes excessive and there is a subjective conviction - despite a normal appearance - that one is particularly ugly or deformed, then body dysmorphic disorder (or dysmorphophobia) is probably present. Those affected experience parts of their body as deformed and are convinced that other people also notice their flaws. In the presence of a minor abnormality, the concern is greatly exaggerated. The misperceptions often relate to the face, such as the nose, lips, eyes, ears, head shape or face color, the purity of the skin, but also to other body parts and features, such as body size, hands or stomach.

The disorder usually begins in adolescence. Men are affected almost as often as women. It is characterized by a constant preoccupation with the perceived disfigurement as well as severe suffering, including suicidal thoughts and attempts. In order to reduce the (sometimes obsessive) circling of thoughts, but also the associated tension, insecurity and helplessness, patients display numerous safety behaviors: They spend several hours a day in front of mirrors, use make-up, only wear certain clothes or make increased use of medical treatments, they photograph or film themselves non-stop in a wide variety of lighting conditions in order to check their perceived deformity - in the long term, all these efforts remain unsuccessful.

Please contact JUVENIS by phone at +43 1 236 3020by e-mail to empfang@juvenismed.at or via the contact formto make an appointment for a consultation or treatment.

Recognizing and treating self-esteem issues

For fear that someone might see their blemish, those affected avoid various social events and withdraw at home. If the supposed "physical deformity" is apparently discovered by another person, the patient is plagued by strong feelings of shame and tries to leave the situation in a hurry. The core of the disorder is usually a pronounced self-esteem problem. In the course of their development, those affected have not succeeded in tapping into sources of self-worth other than their appearance. The mental preoccupation with the blemish, the constant control and avoidance behavior increasingly determine life, there is hardly any time left for other (professional or private) activities and experiences. In this respect, the disease also has a negative impact on the personality development of young patients.

By neglecting various other areas of life, those affected by body dysmorphic disorder experience increasing frustration and disappointment, which in turn has a negative impact on their self-esteem. They try to stabilize this again by improving their appearance, thus completing the vicious circle. If left untreated, there is a risk of chronic progression and a higher risk of developing another mental disorder (e.g. depression, anxiety disorder or alcohol abuse).

Treatment procedure

Each treatment is preceded by a detailed anamnesis and diagnosis (differential diagnosis). As part of the psychotherapy, an individual explanatory model is created which provides insight into the development of the disorder. This takes into account pre-existing risk factors (e.g. a conflict-ridden family environment, experiences of violence or abuse, exclusion and teasing by peers, inadequate coping strategies, low self-esteem, etc.) as well as triggers (various traumatic experiences).The causes (various traumatic experiences) and maintaining conditions (safety behaviors such as compulsively looking in the mirror, seeking reassurance, head coverings to hide the blemish, make-up, constant tanning of the skin or avoiding publicity, etc.) of the disease. Biological (e.g. obesity), social (e.g. repeated bullying by peers) and psychological (e.g. increased anxiety, lack of coping strategies) influencing factors and their interactions are given equal consideration. It is important for the therapy to determine the functionality of the disorder. For example, a patient's dysmorphophobia could hide a desire for affection and recognition or an attempt to prevent abandonment by optimizing their appearance.

Please contact JUVENIS by phone at +43 1 236 3020by e-mail to empfang@juvenismed.at or via the contact formto make an appointment for a consultation or treatment.

Psychotherapy for body dysmorphic disorder (dysmorphophobia)

  • Therapeutic relationship: The relationship between client and psychotherapist is an important factor in treatment. Within this framework, problems from the entire lifespan, i.e. stresses from childhood, difficulties in current life and fears/anxieties about the future, can be dealt with. The therapist provides support in coping and tries to maintain a balance between change and stabilization. The better the therapeutic relationship, the more successful the therapy will be.

  • Psychoeducation: The patient receives information about body dysmorphic disorder, the development, possible progression and maintenance of symptoms, as well as treatment options. An individualized model of the disorder is developed, thus promoting the patient's understanding of the problem. The patient should become an expert on their illness. The patient's knowledge of the disorder has a demonstrably positive influence on the healing process.

  • Increasing self-esteem: Many of those affected have had negative relationship experiences in the past. In psychotherapy, it is the therapist's task to focus on the client's needs (complementary relationship design, Stucki 2007) and thus strengthen their self-esteem. The appreciative behavior of the therapist is a new and corrective experience for many patients. As self-esteem improves, the dreaded feelings of shame also diminish.

  • Cognitive therapy: Dysfunctional basic assumptions (e.g. "If I'm not attractive, I'm not worth anything" etc.) of the patient are identified and questioned using cognitive (cognition = thought) techniques, checked for their reality and corrected.

  • Exposure in vivo: The patient is asked to refrain from safety behaviors (e.g. applying make-up, combing or styling hair, avoiding large crowds, etc.) and to endure their fears until they subside. In this way, the patient gains corrective experience.

  • Show weakness: Patients believe that they must always be strong, otherwise - they assume - their weakness would be used against them. During therapy, those affected learn to show their weaknesses. The perfect appearance often serves as protection against attacks.

Please contact JUVENIS by phone at +43 1 236 3020by e-mail to empfang@juvenismed.at or via the contact formto make an appointment for a consultation or treatment.

  • Change in feelings of shame: Patients with body dysmorphic disorder were often shamed in their childhood. These experiences usually had a negative impact on the self-esteem of those affected. By improving their appearance, they try to stabilize their self-esteem and reduce their shame. The traumatic experiences that led to shame in the past must be dealt with as part of the therapy.

  • Methods for changing negative body image (Brunhoeber, 2009):

    Rope exercise: The patient uses a rope to measure the estimated circumference of various body parts (e.g. head). The actual circumference is measured with another rope and compared with the patient's estimate. This illustrates the distorted body perception.

    Body outline drawing: The patient draws the estimated circumference of their entire body on a flip chart. The paper is then hung on the wall and the actual body circumference is traced with a different colored pen.

    Drawing the facial features: The patient is asked to draw his/her face on a transparent sheet from imagination. A digital photo of the patient's face is taken beforehand. The transparent film is placed over the photo on the PC screen in order to relate perception to reality.

    Video exposure: First the entire body is filmed from all sides with a camera and then certain parts of the body (nose, head, eyelids etc.) - duration: approx. 5 to 10 minutes. The recordings are then viewed together - without judging!

    Mirror confrontation: The patient is confronted with his/her mirror image and asked to describe individual body parts without evaluating them.

    Phototherapy: The face and individual body parts (nose, eyelids, stomach, etc.) are photographed. The patient is confronted with the photos and asked to describe the individual body parts without judging them.

  • Reduction of compulsive mirror gazing: The mirror image can trigger memories of traumatic experiences (e.g. teasing because of appearance). Those affected by body dysmorphic disorder are given specific behavioral instructions for handling and using mirrors (from Veale, 2001 in Brunhoeber, 2009): Do not get too close, use large mirrors, do not draw attention to their feelings, use the mirror only for basic activities (such as shaving) and only for a limited time, look at the whole face and not individual parts, do not use magnifying mirrors, do not use a mirror when feeling depressed. All unnecessary mirrors should be removed, etc.

Please contact JUVENIS by phone at +43 1 236 3020by e-mail to empfang@juvenismed.at or via the contact formto make an appointment for a consultation or treatment.

  • Changing dysfunctional behaviors: At a young age, many of those affected have repeatedly experienced being excluded or ridiculed because of their appearance. Based on these experiences, specific basic assumptions (sometimes unconscious beliefs) have developed, such as "if I am not attractive, I am not worth anything, I will be excluded, I will fail, etc." Patients' self-esteem is heavily dependent on their perceived attractiveness, and all negative reactions from those around them and any rejection are attributed to their own appearance. The optimization of the external appearance is considered by those affected as a solution to various problems, while constructive problem-solving strategies are only insufficiently developed. For patients with body dysmorphic disorder, improving their appearance (e.g. through surgery, various peelings, etc.) only provides short-term emotional relief; in the long term, the problems remain or even intensify. In therapy, it is therefore important to show the patient the negative consequences of all safety behaviors (e.g. checking in the mirror, measuring body parts, constant reassurance from other people, dieting, surgical procedures, hours of styling, social withdrawal, etc.) and to discuss alternative, constructive solutions and integrate them into everyday life.

  • Mindfulness: Mindfulness exercises (e.g. body scan, breathing meditation) are used to gradually distance oneself from negative emotions and thoughts.

  • Treatment of background problems: As therapy progresses and the body dysmorphic symptoms are alleviated, background problems such as social competence deficits, difficulties in affect regulation or personality accentuations usually become apparent, which are taken into account in the further course of treatment.

  • In addition, medication (antidepressants, SSRIs) is often recommended by a psychiatrist.

Costs

Treatment Price
1 therapy session for body dysmorphic disorder (50 minutes) € 110

A frequency of 1 therapy session per week is usual.

The costs of "clinical-psychological treatment" are not reimbursed by the health insurance company. Some private supplementary insurances often cover part of the costs - however, patients should ask their supplementary insurer about this.

It is also possible to deduct clinical-psychological treatment from tax as an extraordinary burden. 

Team

Hilde Winkler

Hilde Winkler

Psychotherapist (behavioral therapy), clinical and health psychologist, occupational psychologist
Curriculum vitae

Dorothea Bertram

Clinical and health psychologist, psychotherapist (behavioral therapy)
Curriculum vitae

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