Body dysmorphic disorder: a therapist's manual

1. The programme at a glance

Indication. Body dysmorphic disorder in adults, whatever the degree of insight (section 4), muscle dysmorphia included (section 38). One section adapts the programme to adolescents (section 40).

Reference model. A cognitive behavioural therapy specific to the disorder, as described in the published manuals of Wilhelm, Phillips and Steketee (2013) and of Veale and Neziroglu (2010): formulation, motivational work, exposure with response prevention (section 35), perceptual mirror retraining (section 36), cognitive restructuring and relapse prevention. The cognitive model of Veale (2004) gives its logic (section 5).

Format. Sixteen weekly sessions of 60 minutes, extended to 90 minutes when exposure takes place in session or outside. Two booster sessions, at one month and at three months. That is the volume of the trial by Veale, Anson et al. (2014), and it is close to the fourteen-session protocol evaluated in adolescents (Mataix-Cols et al., 2015). Other evaluated protocols are longer: the trials by Wilhelm et al. ran to twenty-two sessions over twenty-four weeks (2014, 2019). Severe forms may require more.

Mechanism targeted. Not appearance, nor the view the person takes of it, but what keeps the preoccupation going: attention fixed on an inner image of oneself, incessant comparisons, and rituals — checking, camouflaging, seeking reassurance, avoiding — which bring little relief and confirm each time that the problem really is appearance (section 5).

Session	Focus	Session output
1	Assess, measure, make safe	Baseline measures, risk assessed, safety plan
2	Two hypotheses	Hypotheses written down, goals, suspension of cosmetic procedures proposed
3	The formulation	The cycle written in the person's own words
4	Rituals and checking	Inventory, first ritual stopped
5	The mirror	Mirror rules, first neutral description
6	Camouflage and the ladder	Exposure ladder rated
7	The first exposure	One outing without camouflage, prediction tested
8	Attention and comparisons	Exposure with attention turned outwards
9	Reassurance and those close by	Written agreement with someone close
10	Thoughts	Two behavioural experiments
11	The mirror, second stage	Whole-body description, without rituals
12	Surgery and cosmetic procedures	Written decision, coordination agreed if the person accepts it
13	What appearance is supposed to bring	Core belief re-rated
14	Taking back what was given up	Three dated resumptions
15	Consolidating	Ritual-free week planned
16	Personal plan and relapse prevention	Written plan, measures repeated

In this table, "the two hypotheses" are the engagement tool described in section 6, and "the cycle" is the vicious cycle that keeps the preoccupation going (section 5).

What the person takes away. Ten printable worksheets, listed in section 45: my record, my safety plan, my cycle, my rituals, the mirror differently, my ladder and my exposures, what I tell myself, before a cosmetic procedure, the corner for those close by, my plan for what comes next.

What distinguishes this programme from the other manuals on this site. Three things. One rule held to in every session: appearance is never discussed; a second hypothesis is offered and put to the test. A safety plan offered to everyone, because suicide risk is high and is rarely spoken of (section 10). And a whole section on requests for cosmetic procedures, neither forbidden nor fought, but suspended and discussed with those who carry them out.

2. Before you begin

The four preliminary decisions

Is there current suicide risk? It is common in this disorder, it is asked about explicitly, and it is treated first or at the same time. Section 10.

Is a cosmetic procedure booked? If surgery, an injection or a treatment is planned in the coming weeks, session 12 moves up to third place. Section 11.

Is this really body dysmorphic disorder? And not an eating disorder, social anxiety, depression or a psychotic disorder. Sections 3 and 8.

Does the severity call for combined treatment? When the impact is severe, the recommendation of NICE, the British institute that publishes guidelines on good clinical practice, is to add a selective serotonin reuptake inhibitor to therapy (National Institute for Health and Care Excellence, 2005). That is decided with a doctor from the outset. Section 15.

What this programme does not treat

It does not treat a suicidal crisis on its own. When the risk is high and immediate, safety comes first, and the manual Suicidal behaviour in adults: a therapist's manual takes over.

It does not treat an eating disorder. The manuals Anorexia nervosa: a therapist's manual and Bulimia and binge-eating disorder: a therapist's manual then apply.

It does not replace a medical opinion when a real physical feature — a skin condition, a scar, hair loss — deserves treatment. Section 11.

How to use it

Read the whole text before the first session, in particular sections 6, 10, 11, 35 and 36: the model, suicide risk, requests for cosmetic procedures, exposure and the mirror. Each session is described using the same framework: the aim, the steps, what you say, common mistakes, and the criterion for moving on.

Three warnings specific to this presenting problem.

The person almost never comes for this. They come for depression, social anxiety, dropping out of school or work — or they are referred by a dermatologist or a surgeon. Shame means they will not spontaneously say what occupies them for hours a day. You have to ask.

They do not think they have a psychological problem. They think they have a problem with their skin, their nose or their build. That is why session 2 exists, and why it does not consist in convincing them otherwise.

And reassurance lies in wait for you. Saying "but there is nothing to see" is the most natural reflex in the world. It is also the first ritual you would be performing on their behalf.

3. Four pictures not to be confused

1. Ordinary preoccupation

What you observe. Dissatisfaction about a part of the body, sometimes keen, without organised rituals or avoidance. The person can think about something else, go out, be photographed.

What that implies. No treatment.

2. Body dysmorphic disorder

What you observe. A preoccupation that takes hours, about a feature that others do not see or consider minimal, with rituals — mirror, comparison, camouflage, endless grooming, requests for reassurance — and avoidance that narrows life.

What points to it. The gap between what the person sees and what others see, and the way the day is organised around that feature.

What that implies. It is the programme described here.

3. A real and visible feature

What you observe. A scar, a malformation, an obvious skin condition, with suffering proportionate to what can be seen.

What points to it. Proportion. When a slight feature does exist but the preoccupation is manifestly out of proportion, a diagnosis of body dysmorphic disorder remains possible.

What that implies. Support for adjusting to a visible difference and, where appropriate, medical treatment.

4. An eating disorder

What you observe. The preoccupation is about weight or shape, with restriction, binges or compensatory behaviours.

What that implies. Another manual, even though the two disorders can coexist. Section 8.

The three sorting questions

"Is there a part of your appearance that preoccupies you a great deal, and that you would like to think about less?" It opens the door. Shame means it has to be asked, not waited for.

"How much time a day do you think about it, counting everything?" It separates ordinary preoccupation from the disorder. In the screening questions it proposes, the NICE recommendation takes thinking about it for more than an hour a day to be excessive (National Institute for Health and Care Excellence, 2005).

"What does it stop you doing?" It measures the impact and brings avoidance to light.

4. What you observe

The preoccupation

What you observe. Thoughts about one or several areas — the skin, the nose, the hair, the teeth, the eyes, the stomach, the genitals, facial symmetry, build — which come back endlessly, are hard to set aside, and often take up several hours a day. The area can change over the years, and several areas often coexist.

What the person says. "Disfigured", "monstrous", "deformed", "hideous". Rarely "not very nice-looking". The vocabulary is clinical information.

The rituals

What you observe. Repetitive behaviours in response to the preoccupation: looking at oneself in the mirror or in any reflecting surface, grooming or applying make-up at length, doing and redoing one's hair, touching or feeling the area, picking at the skin, changing clothes, photographing oneself and comparing the photos, asking whether "it shows", searching online for treatments or opinions.

Mental rituals. Comparing one's appearance with that of others, in the street as much as on screens, is the most frequent, and it is almost always forgotten because it cannot be seen.

Camouflage

What you observe. Make-up, hairstyle, cap, glasses, beard, loose or layered clothing, posture, a hand in front of the mouth, a seat chosen in the shade, a profile presented to others. It is often so long-standing that the person no longer notices it. It is a safety behaviour: it prevents the discovery that the feature, once shown, does not produce what is feared.

Avoidance

What you observe. Photographs, swimming pools, dates, sex, daylight, classes, video calls, and sometimes going out at all.

Ideas of reference

What you observe. The conviction that others notice the feature, look at it, talk about it or mock it. The International Classification of Diseases (ICD-11) makes this a frequent manifestation of the disorder. They do not, on their own, indicate a psychotic disorder.

Insight

What you observe. A continuum running from "I know I am probably exaggerating" to the certainty of being disfigured. In a direct comparison with obsessive-compulsive disorder (OCD), the majority of people with body dysmorphic disorder had poor or absent insight, whereas the majority of people with OCD had good or excellent insight (Phillips et al., 2012).

What that changes. Less than one might think. People who are convinced respond to therapy and to serotonin reuptake inhibitors (Veale, Anson et al., 2014; Phillips et al., 2002). What does change is the way the work is engaged: session 2.

The impact

It is often massive: studies interrupted, employment lost, isolation, emotional life suspended, considerable expense. Muscle dysmorphia, which has its own features, is covered in section 38.

5. What keeps the disorder going

Four mechanisms, and the treatment targets all of them.

Self-focused attention, and the inner image

In social situations and in front of the mirror, attention fixes on the area and on an inner image of oneself, vivid and distorted, rather than on what is really visible or on other people (Veale, 2004). The more attention narrows, the more the detail grows, and the truer the inner image seems. In affected people, even a brief spell in front of the mirror appears to be enough to trigger this self-focused attention and the distress that goes with it (Windheim et al., 2011).

What the treatment does with it. It moves attention outwards and towards the whole. Sessions 5, 8 and 11.

Judgement and comparison

The image is judged against idealised standards, by comparison with others, and every comparison is lost in advance since it sets an isolated area against whole faces. Rumination is added to it: "why me", "what if it got worse".

Rituals, camouflage and avoidance

They sometimes relieve, they rarely reassure, and they always prevent the same thing: discovering that the feature, seen as a whole and uncorrected, does not produce the rejection that is feared. Each ritual also confirms that the problem is appearance, since it is being attended to. Time at the mirror, in particular, does not follow the simple model of a check that soothes: it is a sequence of safety behaviours from which people almost always emerge feeling worse (Veale and Riley, 2001).

The value placed on appearance

Behind the preoccupation there is almost always an equation: "if I am ugly, I am worthless", "nobody can love me like this", "until this is sorted out, my life cannot begin". Appearance has become the measure of personal worth. Teasing or bullying is often found in the history, and negative, distorted images of oneself may be linked to the memory of those events (Willson et al., 2016).

What the treatment does with it. Session 13.

The complete cycle

A trigger — a reflection, a photo, a light, a glance — draws attention to the area. The inner image takes over. It is judged, compared, and shame or anxiety rises. A ritual follows, or avoidance. It brings little or no relief, and it confirms that the problem is appearance. The preoccupation comes back faster the next time.

That is the diagram you draw in session 3.

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