Cognitive Behaviour Therapy in Body Dysmorphic Disorder - Research Paper Example

Body Dysmorphic disorder is a psychiatric condition, mostly affecting females and the condition makes the patient obsessive about a perceived defect in a body part. One of the treatment methods that has been advocated in this regard is cognitive behaviour therapy, which aims to restructure a patient’s thinking patterns in dealing with the anxiety. This study puts forward the hypothesis that CBT may be effective in treating BDM. The existing literature suggests that CBT may be effective because it operates through cognitive restructuring. A mixed methods approach is utilized, using two groups of 60 female participants in the age group of 18 to 21. Participants are to be selected through random sampling. The research procedure to be used will be experimental, with a control group whose serotonin levels, heart rate and other measures will be tested before and after the test using a t-test. This will be supplemented with survey questionnaires and the hypothesis will be rejected at 0.05. Cognitive Behaviour Therapy Introduction: Body dysmorphic disorder is a psychiatric condition that is associated with anxiety about one’s body image, especially common in female teenagers and young women. The patient obsesses about a perceived defect and assumes that it makes her look very ugly, while this might not be the case because the patient might actually look quite normal. One of the problems associated with this is that the condition is associated with extreme levels of anxiety that might even deteriorate to the point where it translated into acute depression. In a meta-analytic review of cognitive behavioural interventions which have been used in treating anxiety and depression, Smits et al (2008) found that the use of CBT had been found to be efficacious in the treatment of anxiety; as a result, it may also be possible to apply it effectively in treating the anxiety associated with body dysmorphic disorder in females. It must be pointed out however, that while there are some studies which have been carried out on CBT and its efficacy in alleviating anxiety in general, the results are not conclusive enough to be applied on a generalized basis. The problem which arises in this context is: can CBT be applied specifically in the context of 18 to 21 year old females who are suffering from anxiety associated with body dysmorphic disorder, in order to alleviate such anxieties? The hypothesis that is put forward in this study is as follows: Cognitive Behaviour Therapy may be efficacious in females who have been diagnosed with body dysmorphic disorder between the ages of 18 to 21. Literature Review: Body dysmorphic disorder is a relatively severe psychiatric disorder wherein patients who have it appear to think they look ugly or deformed although in reality, they may be quite normal (Phillips, 1991). The definition of DSM IV TR is that it’s “a condition marked by excessive pre-occupation with an imaginary or minor defect in a facial feature or localized part of the body” (www.minddisorders.com). In arriving at an assessment of BDM, the condition needs to be severe enough to cause significant disruptions to the patient’s “social, occupational, or educational functioning.” BMD is a preoccupation with an imagined defect in appearance, with a person becoming markedly concerned about it, to the extent that there may be depression, distress and impairment in social, occupational and other areas of functioning. In a study carried out by Smits et al (2008), a computerized search of 989 studies were identified, wherein 24 randomized trials and 1851 participants were included in assessing the efficacy of Cognitive Behavioural Therapy vis a vis control conditions in reducing anxiety. Their review showed that CBT was efficacious in reducing anxiety. In one cross cultural study, the prevalence of BDD was compared in non clinical samples of 101 American and 133 German students and found similar instances of the disease in both the groups. (Bohne et al, 2002). In another study BMD was found to be associated with feelings of low self esteem, shame, unworthiness and feeling unlovable, with nearly half the patients being delusional, i.e, completely certain that they look abnormal, whereas they may not really look that way (Phillips et al, 1993). Studies which have been carried out in outpatient settings have revealed that among patients suffering from BDD, about 8% were suffering from major depression while 14-42% of the patients were suffering from a major atypical depression (Phillips and Castle, 2002). The efficacy of Cognitive Behaviour Therapy has been assessed in studies, which have shown them to be quite effective (Nezirgolu and Patel, 2002). In applying treatment under the cognitive behaviour therapy approach, Marks and Mishan (1988) have applied a combined approach, i.e, they have applied a cognitive restructuring process in which the faulty perceptions that patients have about their body image and their obsession about their appearance are combined with the modification of certain behavioural components, such as reducing the high levels of social avoidance that these participants experience as a result of their fixation with their appearance. This would also include such measures like reducing the indigence of checking mirrors, grooming oneself endlessly or constantly obsessing about the body party which causes them distress. Marks and Mishan (1988) found that this combined approach appeared to work quite well in achieving successful outcomes in alleviating the anxieties that BDM clients had about their appearance. Nezirgolu et al (1996) carried out preliminary case studies using exposure therapy and cognitive behavioural techniques with BDM patients. Subsequently, they had 17 patients, each of whom received 4 weeks of CBT sessions daily, each ranging over a 90 minute period, or 20 sessions in all, there was a significant reduction in the severity of incidence of BDM. The results obtained on this study were also corroborated in another study by Wilhelm et al (1999), where an open series of 13 patients were treated with cognitive behavioural therapy administered in groups over twelve 90 minute sessions each. The results showed that there was a significant improvement in the body dysmorphic disorder condition, thereby further adding to the inference that CBT could be helpful in alleviating the attendant anxiety associated with the disease condition. Methodology: As evidenced by the literature review, CBT may be useful in treating the condition of BDM. While studies cited above have shown that CBT could be helpful, the results are not however, conclusive enough to be applied on a large scale basis. This study proposes to add to the pool of research by undertaking a further examination into whether cognitive behavioural therapy could be beneficial specifically in the case of 18 to 29 year old females, suffering from anxieties about their bodies. At the outset, the hypothesis posed in this study is that Cognitive Behaviour Therapy may be efficacious in treating the symptoms of anxiety associated with Body Dysmorphic disorder. Research method: The mixed methods design is chosen for this research since it the appropriate method to assess the research questions and objectives. A qualitative approach, i.e, an approach involving any kind of research where the findings are not derived based on “statistical procedures or other means of quantification” (Strauss and Corbin, 1990:17) may be appropriate for this study, but cannot be effectively measures without a quantitative element. Qualitative methods are relevant when the issues under study, such as anxiety in this case, are subjective (Trochim, 2001), but a quantitative approach on the other hand, is useful because such an approach would place a strong reliance on empirical data, which relies on numerical measures. An experimental approach is proposed, using a control group and an experimental group. The latter group only will be treated using CBT, although all participants will have their serotonin levels measured at the outset. Participants: 120 female participants in the city of Tennessee who show symptoms of BDM will be selected to participate in the study. Selection would occur after an initial survey/examination to identify their symptoms on the basis of those identified by a DSM-IV diagnosis. The criteria for inclusion in the study would require conformity to the symptoms prescribed under such a diagnosis, i.e, (a) preoccupation with non existent defect in body appearance (b) anxiety or depression and (c) impairment in social functioning. The survey questionnaire would be the most useful in terms of identifying those who are likely to be suffering from body dysmorphic disorder and experiencing anxiety on this account. The initial survey will extract respondents by cluster sampling and systematic random selection from within the city of Tennessee. Using these procedures will yield an equal probability of selection. The total sample size would be 120 females in the age range of 18 to 21, although it is expected that some participants could fall slightly out of this range. The first step in cluster sampling is to divide the population into cluster units. Within these cluster units, the researcher will randomly choose areas where the survey will be conducted. This method will save travelling time and consequently reduce cost. After cluster sampling, each respondent will be systematically chosen by dividing the number of households within the cluster unit by the desired number of respondents (e.g. 150 households/ 25 respondents is equal to six intervals). That will be the interval count in randomly selecting survey respondents, after ensuring that they fall within the parameters for the study, i.e, (a) aged between 18 to 21 and (b) suffering from BDM. The data gatherer will conduct the survey and give the self-administered questionnaires to the prospective respondents. Each survey will take 15-30 minutes to finish. Ethical Issues: The researcher will obtain an informed consent from all participants. This will protect their anonymity and the confidentiality of their cases throughout the conduct of the study and provide the assurance that all information would only be used for the purposes of this study. Before beginning the data collection procedure through the survey questionnaire and interviews, participants will read and sign an informed consent letter that explains the purpose of the study and the estimated time of the interview. This letter would reiterate that participation is voluntary and that they can opt out whenever they feel like it. The credibility and integrity of the study would thus be safeguarded through the informed consent and confidentiality measures proposed to be instituted and the care which would be taken to ensure that bias does not play a role in analysis of the results. Research Procedure: This study seeks to assess the efficacy of CBT in treating BDM. The Independent Variables selected in the study are (a) the levels of serotonin in the patient’s brain and (c) exposure to images on television. The serotonin levels will be assessed through a blood test, while the other independent variables will be assessed through the survey/interview. The primary dependent variable is the concomitant anxiety which is associated with BDM; anxiety that is continuous or sustained over the previous year. A secondary dependent variable is the incidence of childhood trauma and if it is found, how it impacts upon the mental state of the patient in producing anxiety. The participants identified through the sampling process will be divided into two groups of 60 each – the experimental and control groups. The study will use a pre-test, post-test approach. All participants would initially have their serotonin levels measured, to either supplement or negate the levels of serotonin as a predisposing factor causing BDM. Secondly, all participants would be questioned and asked to examine their images in the mirror, to assess anxiety, by measuring both autonomic nervous system changes and overt behavioral performance, by using electrodes on the participants’ arms and legs to measure emotional arousal, coupled with observation of behavior. Heart rate and skin conductance levels will also be measured. Similar measurements would be derived at the end of the test. The experimental group would receive treatment based on the cognitive behavioural approach, i.e, cognitive restructuring aimed at changing the participant’s mental perception about her own image. The objective will be to challenge existing beliefs about flawed body image. This is proposed to be achieved by ensuring that each participant goes through cognitive sessions of about 90 minute duration, in which the participant will be asked to talk about her body image and the defect that she perceives. Reason and a rational approach will then be applied to question the participant about why she feels this way about herself and to challenge the existing perception, by showing her pictures or videos of females in her age range who are much worse off. When the participant is allowed the opportunity to compare her own image with a much worse one, the perception about one’s own image is likely to improve. This approach will be combined with behavioural components, such as preventing repetitive behaviour that contributes to the anxiety, such as checking image in the mirror and excessive grooming. Through repeated training, the participant will be trained into avoiding such negative behavioural patterns which could contribute towards the development of an adverse self image. The control group on the other hand, will receive no treatment at all geared towards revising the mental concept of self image and thus will serve as the control group to assess the efficacy of the cognitive behavioural approach. Since the control group also comprises females suffering from BDM but they will not receive treatment, the end of the experimental period could be a time when both groups are compared, in order to assess whether treatment patterns have worked. Reliability and validity: The internal validity and reliability of the study could best be preserved by not allowing the element of bias to creep into the evaluations which are done. Moreover, the other earlier studies which have been done already on the subject of body dysmorphic disorder and the efficacy of the CBT approach will be used as a basis to compare the results obtained in this study. If the results appear to support and corroborate each other, then the validity and reliability of this particular study will be established. Discussion and expected results: A t-test would be used to analyze the data collected at the beginning of the test, i.e, pre-test, as well as after the test is completed, i.e, post test. The hypothesis which has been put forward in the study is: Cognitive Behaviour Therapy may be efficacious in females who have been diagnosed with body dysmorphic disorder between the ages of 18 to 21. Based upon the results in the study, if this null hypothesis is supported by the results obtained above, it would suggest that the hypothesis is true and therefore the study can conclude that CBT would also be effective in treating anxiety in females. If the alternative hypothesis is proved however, i.e, that CBT is NOT efficacious in treating females who have been diagnosed with body dysmorphic disorder, then the hypothesis would be untrue and would not be supported by the results of the study. The null hypothesis would be rejected at the 0.05 level. For each individual test instituted to measure anxiety, i.e, measure of heart rate, skin conductance level, serotonin levels, a multivariate, repeated measure ANOVA will be conducted. A Continuous Performance Test (CPT) can also be administered to measure attentional performance and each analyzed, separated within multivariate repeated measures ANOVA. The pre-test scores will be used to determine that there the two groups are similar and that there is little variability among the mean scores and this will be compared to the post test results, using the same measures.The quantitative ratings from these tests which challenge existing beliefs about flawed body image will be analyzed using ANOVA. It is expected however, that the hypothesis will be proved, i.e, that the study will have a favourable prognosis in terms of applicability of CBT in treatment of anxiety in 18 to 21 year old females and the treatment is likely to be effective. In carrying out an analysis of the results, the central focal point of comparison would be the DSM-IV diagnosis, which would be carried out before and at the end of the experimental treatment approach. In the case of patients who have received treatment, it appears likely that the symptoms would have been alleviated, while in the control group, the symptoms are likely to remain more or less the same. These results would be presented in a comparative table, which would list the symptoms reported by the patients prior to and after the completion of the experiment. Conclusions: Body Dysmorphic disorder is a psychiatric condition which is largely generated within the confines of the mind, therefore its symptoms cannot be discerned as easily as other diseases where there are definite external symptoms which can be observed. The efficacy of the results will depend to some extent upon the accuracy of self reporting by the patients of their attendant symptoms, but the tests proposed such as serotonin levels and heart rate, would help to measure them quantitatively. On the basis of the literature review, it would also appear that while CBT has been found to be effective in treating anxiety and depression and also in correcting a negative body image associated with body dysmorphic disorder, the results cannot be applied on a wide ranging basis. Moreover, the findings from earlier studies do not specifically address the efficacy of the treatment in young females between the ages of 18 to 21. This is a limitation that this study is expected to address; however it is also expected that the study will show CBT to be effective in treatment of anxiety associated with body dysmorphic disorder in 18 to 21 year old females as well. As also detailed earlier, the challenge in this study is to effectively apply the appropriate measure towards determining the efficacy of CBT. In conjunction with the tests proposed, it would also be necessary for the researcher to main exhaustive notes about the CBT sessions, in order to assess how the patient is progressing. Although the final result will be presented in graphs and will be based upon the ANOVA results, it will nevertheless be supplemented by case notes on each session and each participant. This would ensure that the results and findings of this study can be well supported by qualitative data that is appropriately coded into categories, so that they can be applied on a generalized basis. It is expected that this study could make a significant contribution to general research in this area and also provide a valuable base of information that could be used for other studies as well. References: * Body Dysmorphic disorder. Retrieved November 10, 2010 from: www.minddisorders.com * Bohne A, Keuthen NJ, Wilhelm S, et al, 2002. “Prevalence of symptoms of body dysmorphic disorder and its correlates: a cross-cultural comparison”, Psychosomatics;43:486–490 * Marks I and Mishan J, 1988. “Dysmorphophobic avoidance with disturbed bodily perception: a pilot study of exposure therapy”, British Journal of Psychiatry, 152:674–678 * Neziroglu F and Khemiani-Patel S, 2002. “A review of cognitive and behavioural treatment for body dysmorphic disorder”, CNS Spectrums, 7:464–471 *Neziroglu F, McKay D, Todaro J, et al, 1996. “Effect of cognitive behavior therapy on persons with body dysmorphic disorder and comorbid axis II diagnoses”, Behavioural Therapy, 27:67–77 *Phillips KA, McElroy SL, Keck PE, Jr, et al, 1993. “Body dysmorphic disorder: 30 cases of imagined ugliness”, American Journal of Psychiatry, 150:302–308 *Phillips KA and Castle DJ, 2002. “Body dysmorphic disorder” IN Castle DJ, Phillips KA, editors. “Disorders of body image”, Wrightson Biomedical: 101–120. *Phillips, K.A., 1991. “Body dysmorphic disorder: the distress of imagined illness”, American Journal of Psychiatry, 148(9): 1138-49 *Smits, J.A, Berry, A.C., Tart, C.D. and Powers, M.B., 2008. “The efficacy of cognitive- behavioural interventions for reducing anxiety sensitivity – a meta-analytic review”, Behaviour Research and Therapy, 46(9):1047-54 *Wilhelm S, Otto MW, Lohr B, et al, 1999. “Cognitive behaviour group therapy for body dysmorphic disorder: a case series”, Behavioural Research Therapy,37:71–75 Read More