Neziroglu BDD Presentation Part 4

Jun 10, 2015 | Author: Bio Behavioral Institute


42. Behavioral Treatment Steps

·        Step 1: Build A Hierarchy

         Targeting avoidance.

         Targeting distressing situations.

         Question patient about a typical day to elicit hierarchy items.


43. Building a Hierarchy

·        Common Distressing Situations

         Mirrors/Shiny surfaces

         Outdoors and bright lighting

         Crowded situations with little personal space

         Shopping centers


         Summer time activities

         Shopping for clothes

         Classroom environment

         Sports activities (swimming)


44. Bill’s Hierarchy

                     Watching himself on his sister’s wedding video

         20        In session with therapist without hat for 1 min.

         25        Driving in car with styled hair without hat

         30        Sitting in last row of movie theater without hat

         40        In session with therapist without hat for 15 mins.

         50        Dining in dimly lit restaurant without hat

         60        Sitting in clinic waiting room without hat

         70        Going out with friends without hat

         80        At home with extended family without styled hair without a hat

         80        Shopping in a supermarket with or without styled hair without a hat

         90        Going to the Barber Shop for a hair cut

         100      Physical activity in a crowded park without hat


45. Behavioral Treatment Steps

·        Step 2: Decrease Compulsive Behaviors (Response Prevention)

         Initially patient may be asked to cover all mirrors in home.

         Give up all cosmetic products.

         Give up special “tools” for skin picking.

·        Step 3: Initial Exposure Exercises

         Gradually expose area of concern

·        Step 4: Exposure Exercises with Exaggeration of the Perceived Flaw

         Use of make-up, clothes etc. to highlight or exaggerate defect paired with gradual exposure to anxiety provoking situations.

·        Step 5: Mirror Re-Training

         Teaching patient to describe appearance in less subjective language.

         Teaching patient how to scan their appearance without spending too much time on one particular body part.

         Teaching patients not to focus and examine details of appearance.


46. Mirror Retraining

·        Identify motivation and criteria for termination

·        Goals for agreed function

·        Use large mirror at slight distance & non-judgemental

·        Minimal or no make up

·        Focus attention on external reflection

·        Scan whole of face or body

·        Use a variety of mirrors & lights

·        No magnifying mirrors

·        Delay response when urge


47. Attentional Exercises

·        Situational refocusing - goal is to refocus attention externally, “focus on the what you can see, hear, smell, textures” or “interrogate the environment” (Clark, Wells, Bogels)

1) In vivo in session in which patient compares the effect of self-focused attention on preoccupation and distress 

2) Homework monitor focus and depth of attention in different contexts

3) Behavioral experiment (increase and decrease self-focus attention)

4) Identify and help client question helpfulness of beliefs about self-focused attention


48. Attentional Exercises: Exploring Assumptions about Self-Focused Attention

·        What is the motivation for being self-focused? Do you feel that being self-focused will help you?

·        Do these assumptions help you live by your goals and values?

·        Would you recommend to other people that they be self-focused? Why?

·        Is it possible that others may see you differently than the picture in your mind? What do you feel influences your impression of your self over time?

·        What are your doubts about being externally focused?

·        Can you make an alternative assumption about being self-focused? (By actively making alternative assumptions you are challenging your initial assumptions about the functional purpose of self-focused attention).


49. Attentional Exercise: Functional Analysis of Self-Focused Attention

·        Activating Event

         Please describe a recent situation in which you were self-focused


         Please describe what you were doing to be excessively self-focused.

         Intended Consequences

         Before you started being self-focused, what did you want to accomplish?


·        Immediate Consequence

         Was there a positive outcome for being self-focused? Did you feel you were doing something to prevent something bad from happening? For example, Were you trying to prevent being humiliated?

         Unintended Consequence

         What effect did being self-focused have? Did it make you more preoccupied with your appearance? Did it make you more anxious?

         What effect did being self-focus have on your friends and family?

         Alternative Directions

         Would being externally focused be more consistent with your values and goals?


50. Task Concentration Training

·        Extension of situational re-focussing

         Originally developed for social anxiety to redirect attention towards task in situation

         Task concentration training consists of three phases

      a) Gaining insight in the role of attention and the effects of heightened self focused attention

            b) Focusing attention outward in non-threatening situations

            c) Focusing attention outward in threatening       situations


48. Task Concentration Training

·        The first step is to monitor the degree of attention in different contexts in a diary. This would record:

a) Situations that trigger distress and preoccupation

b) The degree of anxiety or distress

c) The percentage of concentration that was directed towards each of the three elements: the self, the task, and the environment, at that moment


49. Task Concentration Training Exercises

·        Listening exercise (no eye contact, then with eye contact)

·         Speaking exercise

·        Non-threatening situation

·        Threatening situations

·        Adapt to non-social situations –watching TV, mirror    


50. More on Intrusive Imagery

·        Identify beliefs about imagery (e.g. “The picture in my mind is a reflection of how I look”)  

·        Aim to develop different relationship with memory where it’s just a bad memory rather than something that is relevant now

·        Functional analysis on response to intrusive images. Avoid or check? What are the unintended consequences of response?

·        Occasionally flash forwards       


51. Family Involvement

·        Psycho-education

·        Group therapy

·        Reduce family’s frequency of providing reassurance

·        Reduce family’s accommodating or antagonistic styles

·        Teach family to be a co-therapist/coach for ERP exercises


52. Pharmacotherapy and BDD

·        Effective

o       Clomipramine

o       Fluoxetine

o       Fluvoxamine

o       Pimozide

o       Consider newer SRI’s (Venlafaxine, Citalopram, Lexapro)

·        Ineffective

o       Imipramine

o       Diazepam

o       Trazedone

o       Lithium

o       Alprazolam

o       ECT


53. Pharmacologic treatment of BDD

·        Research on pharmacotherapy received by individuals with body dysmorphic disorder (BDD) is limited, though it appears that the use of anti-depressants has the most effect in treatment of BDD

·        72.9% of 151 subjects had received psychotropic medication.


·         Most common type ever received was an SRI (65.6%), followed by non-SRI antidepressants (41.1%) and benzodiazepines (27.2%).

·        Phillps et al. (2006)

·        Subjects with lifetime OCD or greater lifetime impairment due to BDD were more likely to have received an SRI specifically.

·        Only 12.9% of SRI trials were considered optimal for BDD, and an additional 21.5% were considered minimally adequate.


54. A Call for New Treatment Options

·        When an individual fails to respond to treatment we as professionals:

         offer them more intense or frequent CBT

         higher dosages or different SSRIs


55. The Third Wave

·        Mindfulness based and contextually focused therapeutic interventions

·        Dialectical Behavior Therapy (Linehan, 1993)

·        Functional Analytic Psychotherapy (Kohlenberg & Tsai, 1991)

·        Mindfulness-Based Cognitive Therapy (Segal, Williams, & Teasdale, 2002)

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