Available online at www.sciencedirect.com

Behavior Therapy 42 (2011) 624–633www.elsevier.com/locate/bt

Modular Cognitive–Behavioral Therapy for BodyDysmorphic Disorder

Sabine WilhelmMassachusetts General Hospital and Harvard Medical School

Katharine A. PhillipsRhode Island Hospital, Butler Hospital, and Alpert Medical School of Brown University

Jeanne M. FamaMassachusetts General Hospital and Harvard Medical School

Jennifer L. GreenbergMassachusetts General Hospital and Harvard Medical School

Gail SteketeeBoston University

This study pilot tested a newly developed modularcognitive–behavioral therapy (CBT) treatment manual forbody dysmorphic disorder (BDD). We tested feasibility,acceptability, and treatment outcome in a sample of 12adults with primary BDD. Treatment was delivered inweekly individual sessions over 18 or 22 weeks. Standard-ized clinician ratings and self-report measures were used toassess BDD and related symptoms pre- and posttreatmentand at 3- and 6-month follow-ups. At posttreatment, BDD

Thisworkwas supported in part by theNational Institute ofMentalHealth Grant R34MH070490 (PI: Wilhelm). We would like to thankUlrike Buhlmann, Ph.D., Aparna Keshaviah, Sc.M., Katherine Crowe,and Tracy Singer for their work on the current study.

Drs. Wilhelm, Phillips, Fama, and Steketee, Fama have receivedresearch support from NIMH for this study (NIMH Grant R34MH070490, PI: Wilhelm). Drs. Wilhelm, Phillips, and Steketeeanticipate royalties from their CBT treatment manual (in press,Guilford Press).

Address correspondence to Sabine Wilhelm, Ph.D., Massachu-setts General Hospital, Simches Research Building, 185 CambridgeStreet, Suite 2282, Boston,MA 02114; e-mail: wilhelm@psych.mgh.harvard.edu.0005-7894/xx/xxx-xxx/$1.00/0© 2011 Association for Behavioral and Cognitive Therapies. Published byElsevier Ltd. All rights reserved.

and related symptoms (e.g., mood) were significantlyimproved. Treatment gains were maintained at follow-up.A relatively low drop-out rate, high patient satisfactionratings, and patient feedback indicated that the treatmentwas highly acceptable to patients. To our knowledge, thisrepresents the first test of a broadly applicable, individualpsychosocial treatment for BDD.

Keywords: body dysmorphic disorder; BDD; cognitive-behavioraltherapy; body image; treatment

Body dysmorphic disorder (BDD) is a severe bodyimage disorder consisting of an often-delusionalpreoccupation with an imagined or slight defect inappearance (American Psychological Association,1994). This preoccupation causes clinically signifi-cant distress or impairment in social, occupational,or other important areas of functioning, and it is notbetter accounted for by anothermental disorder (e.g.,dissatisfaction with body shape and size in anorexianervosa). BDD is a common disorder; nationwidesurveys have found a point prevalence of 1.7 to 2.4%

625modular cbt for body dysmorphic disorder

(Buhlmann et al., 2010; Koran, Abujaoude, Large, &Serpe, 2008; Rief, Buhlmann, Wilhelm, Borkenhagen,& Brähler, 2006). BDD usually begins duringearly adolescence (Phillips & Diaz, 1997; Phillips,Didie, et al., 2006) and, when untreated, the disorderis often chronic and unremitting (Phillips, Pagano,Menard, & Stout, 2006). BDD is associated withhigh lifetime rates of psychiatric hospitalization(48%), being housebound (31%; Phillips & Diaz,1997), and high rates of suicidality. In cross-sectionalstudies, lifetime suicidal ideation rates are 78–81%,and lifetime suicide attempt rates are 24–28%(Perugi et al., 1997; Phillips, Coles, et al., 2005;Phillips & Diaz, 1997; Phillips & Menard, 2006;Veale, Boocock, et al., 1996). This suicide attemptrate is 6–23 times higher than in the U.S. population.Completed suicide has been reported (Atiullah &Phillips, 2001; Cotterill, 1981; Cotterill & Cunliffe,1997; Phillips & Menard, 2006; Veale, Boocock, etal., 1996; Yamada, Kobashi, Shigemoto, & Ota,1978). When controlling for age, gender, andgeographic region, the standardized mortality ratiois markedly elevated (American PsychologicalAssociation, 2003; Harris & Barraclough, 1997).Despite BDD's relatively high prevalence andsubstantial morbidity, no widely applicable man-ualized psychosocial treatment has been testedfor this complex disorder.Treatments for other disorders are not applicable to

BDD because there are important differences betweensymptoms of BDD and those of other disorders(Phillips, 2005). Differences include the content of thepreoccupation (appearance), specific repetitive andavoidance behaviors (e.g., surgery seeking, mirrorchecking, skin picking, compulsive grooming), per-ceptual distortions, and poor insight, which aretypically present in BDD but not disorders such asobsessive-compulsive disorder (Eisen, Phillips, Coles,& Rasmussen, 2004). Thus, a treatment that specif-ically targets BDD's unique symptoms is greatlyneeded.Preliminary research suggests that cognitive–

behavioral therapy (CBT) specially developed toaddress the unique features of BDD is promising forthis severe disorder. A growing literature—consistingof case reports, case series, and two studies usingwait-list control groups (for review see Ipser, Sander,& Stein, 2009)—suggests the effectiveness of cogni-tive and behavioral techniques, such as cognitiverestructuring and exposure and ritual preventionexercises, in reducing BDD symptoms when deliv-ered individually (McKay et al., 1997; Neziroglu,1996; Veale, Gournay, et al., 1996) or in a group-therapy format (Rosen, Reiter, & Orosan, 1995;Wilhelm, Otto, Lohr, & Deckersbach, 1999). InWilhelm et al.'s (1999) study of groupCBT for BDD,

BDD symptoms and depressive symptoms signifi-cantly improved. These preliminary findings are en-couraging; however, limitations of these early studiesraise questions about the generalizability and repli-cability of their results. For example, some individualtreatments (McKay et al., 1997; Neziroglu, 1996)used lengthy (e.g., 2 hours) and frequent (e.g., daily)sessions that are difficult to employ in clinicalsettings, given third-party reimbursement policies.In addition, most studies had restrictive inclusioncriteria that reduced sample representativeness, somestudies included patients who appeared to have mildor even subclinical BDD, and few studies includedmen, even though about 40% of those with BDD aremale (Koran et al., 2008; Rief et al., 2006).One studyexcluded delusional patients, even though more thanone-third of patients currently have delusional BDDbeliefs (Phillips, Menard, Pagano, Fay, & Stout,2006). Thus, it is unclear whether the treatment issuitable for such patients.Only two prior studies used a treatment manual.

Rosen et al.'s (1995) brief group treatment manualfocuses mostly on weight and shape concerns,whereas BDD patients usually focus on other bodyareas, such as skin, hair, or facial features (Phillips &Diaz, 1997; Phillips, Menard, Fay, & Weisberg,2005). Thus, Rosen et al.'s manual does not apply tothe large majority of BDD patients. This manualremains unpublished. Wilhelm et al. (1999; a caseseries) employed a very preliminary version of themanual used in the study described in this report;however, this manual was also developed for a grouptreatment. Neither Rosen et al.'s nor Wilhelm et al.'smanual were developed for individualized treatment,norwere they very detailed or personalized to addressall of the heterogeneous symptoms of BDD. The lackof a widely applicable CBT manual for clinical andresearch use has been a major limitation for the field.Thus, we (Wilhelm, Phillips, & Steketee, in press)

developed a broadly applicable treatment manualthat focuses specifically on BDD symptoms and isbased on our BDD model, which has been informedby prior theories of BDD (e.g., Veale, Gournay, et al.,1996;Wilhelm&Neziroglu, 2002). Our CBTmodel(e.g., Wilhelm, Buhlmann, Cook, Greenberg, &Dimaite, 2010) is based on the premise that in-dividuals with BDD misinterpret visual input ofnormal appearance features or minor appearanceflaws in biased ways that result in negative cognitive,emotional, and behavioral consequences of BDD.Our cognitive–behavioral model proposes that in-dividuals with BDD selectively attend to specificaspects of appearance or minor appearance flaws.This theory is informed by clinical observations andneurocognitive findings (Deckersbach et al., 2000;Feusner, Moody, et al., 2010; Feusner, Townsend,

626 wilhelm et al .

Bystritsky,&Bookheimer, 2007),which suggest thatpatients overfocus on details rather than holisticelements of a visual stimuli. Furthermore, accordingto our cognitive–behavioral model, individuals withBDD tend to exaggerate the meaning and importanceof these minor, or even nonexistent, physical imper-fections. For example, an individual with BDD canmisinterpret a blemish as a reflection of low personalworth (Buhlmann, Teachman, Naumann, Fehlinger,&Rief, 2009; Veale, Boocock, et al., 1996). Sufferersreact to negative interpretations of minor or evennonexistent flaws with anxiety, depressed mood,shame, and further excessive attention to theperceived flaws. Additionally, the model postulatesthat negative feelings resulting from this faultycognitive processing lead to attempts to neutralizethese feelings with ritualistic behaviors (e.g., surgeryseeking) and avoidance of situations (e.g., socialsituations) that trigger these unpleasant feelings.Because these ritualistic behaviors and avoidancebehaviors sometimes temporarily diminish painfulemotions, they are negatively reinforced, and, in thisway, are hypothesized to maintain dysfunctionalBDD-related behaviors.In addition to targeting the proposed maintenance

factors outlined in the model above, our comprehen-sive manual also addresses limitations of the priormanuals. Our manual is broadly applicable to BDDpatients, including those with delusional beliefs. Itincludes core treatment elements and optional treat-ment modules (see below) that allow for a flexible,personalized treatment for each patient. In additionto using a widely applicable BDD manual, thecurrent study also aimed to address the limitationsof prior studies by including patients who werediverse in terms of gender, symptom severity,delusionality of BDD beliefs, and presence ofcomorbid disorders. Thus, this study is the first totest a broadly applicable, modular, manualizedCBT,specifically developed to address the unique symp-toms of BDD and its associated features (e.g., mood,absent or poor insight).

Methodparticipants

Institutional Review Boards at Massachusetts Gen-eralHospital and ButlerHospital approved the studymethods. Participants were recruited via flyers andbrochures that we posted in the community and sentto clinicians for distribution to their patients (e.g.,mental health professionals, dermatologists, plasticsurgeons) as well as letters to these clinicians andinformation about the study on our programs’ Websites. Recruitment materials included questions suchas “Are you worried about your appearance?”

Interested individuals called to participate in atelephone screen to assess for BDD and make aninitial determination of whether study inclusion/exclusion criteria appeared to bemet. To be includedin the study, all patients had to be diagnosed withprimary DSM-IV BDD (based on the StructuredClinical Interview for DSM-IV [SCID-P; First,Spitzer, Gibbon, & Williams, 1995]) and endorsesymptoms of at least moderate severity (as indicatedby a minimum score of ≥24 on the Yale-BrownObsessive Compulsive Scale Modified for BodyDysmorphic Disorder [BDD-YBOCS; Phillips et al.,1997]). BDD symptoms had to have been present forat least 6 months. Exclusion criteria were activesuicidality and/or the presence of any clinical featuresrequiring a higher level of care than outpatienttreatment; mental retardation (estimated IQ b80 onthe Wechsler Abbreviated Scale of Intelligence[WASI; Wechsler, 1999]), dementia, brain damage,or other cognitive impairment that would interferewith the capacity to engage in CBT; DSM-IV sub-stance abuse or dependence within the past3 months; or bipolar disorder, psychotic disorder(except BDD-related delusional disorder), or border-line personality disorder. We also excluded individ-uals who reported body image concerns accountedfor primarily by weight concerns so as not to includeindividuals whose primary symptoms reflected aneating disorder rather than BDD. Individualswho reported previous treatment with ≥10 sessionsof CBT similar to ours for BDD were excluded.Participants were not allowed to receive any psy-chotherapy other than the study treatment at anytime during the study. Patients receiving psychotro-pic medication were allowed to participate as long asany medication changes had occurred 2 months ormore before the initial evaluation and the patientagreed to refrain from medication changes whileenrolled in the study.A total of 153 individuals were screened by

telephone for this study, 138 of whom wereexcluded for the following reasons: 41 had primar-ily weight concerns that could not be classified asBDD symptoms (e.g., a primary diagnosis of aneating disorder), 23 patients had subthreshold BDDsymptoms, 20 were receiving psychotherapy orwere taking medication that had recently beenchanged or was likely to require a change duringthe study, 15 did not return phone calls, 9 were tooseverely ill (e.g., suicidal) and required a higher levelof care, 5 had BDD symptoms that fluctuatedsubstantially, and 25 were not included for otherreasons (e.g., not interested in participating in astudy, thought the study was too much of a timecommitment, or lived far from the study site).Fifteen individuals were invited to come to the clinic

627modular cbt for body dysmorphic disorder

to participate in an in-person evaluation to deter-mine eligibility; all signed informed consent. Threeindividuals were ineligible due to: mental retarda-tion (n=1), insufficient symptom severity (n=1), orprevious CBT for BDD (n=1). Hence, the finalsample comprised 12 adults who began treatment(of whom eight were recruited at MassachusettsGeneralHospital and four at ButlerHospital/BrownUniversity).Our sample (n=12) included seven females and

five (42%) males. The mean age was 32.2 years(SD=4.6). The mean age of onset of BDD symp-toms was 15.1 years (SD=4.1 years). The majorityof participants (10 of 12) were Caucasian; twoparticipants were Asian. Patients completed a meanof 17.1 (SD=2.0) years of education. Participants’primary appearance concerns included hair (n=4),nose (n=2), skin (n=2), body shape/size (n=2),buttocks (n=1), and height (n=1). BDD was theprimary problem for all patients; however, severalpatients had comorbid conditions. Current Axis Icomorbidity was as follows: major depressivedisorder (n=2); dysthymia (n=6); social phobia(n=3); specific phobia (n=3); obsessive–compulsivedisorder, in partial remission (n=1); posttraumaticstress disorder (n=1); general anxiety disorder(n=1); anxiety disorder not otherwise specified(n=1); binge-eating disorder (n=1); and binge-eating disorder, in partial remission (n=1). One-third of the participants (4 of 12) had previouslyreceived cosmetic treatment for their appearanceconcerns, including multiple surgeries (n=2), der-matologic treatment (n=1), and electrolysis (n=1).Two patients were taking psychiatric medication,one patient was taking fluoxetine and lorazepam,and another patient was taking citalopram.

Procedure

CBT treatment methods are described below.Participants received treatment free of charge andwere compensated $25 for completing follow-upinterviews. Treatmentwas delivered byDrs.Wilhelm,Phillips, or Steketee in individual 60-minute sessionstwiceweekly during the first 4 weeks and onceweeklythereafter. Participants were randomized to one oftwo treatment lengths: 18 sessions (n=5) or 22sessions (n=7). Although somewhat longer than istypical for CBT for other disorders, the longertreatment seemed reasonable, given the severity anddelusionality associated with BDD, as well as ourprior clinical experience with these patients. Further-more, Wilhelm et al.'s study (1999) showed thatsymptoms improved in a linear manner with noasymptotic decline in efficacy over 12 sessions,suggesting that additional sessions might have led tofurther gains. Other researchers in the field have also

recommended longer treatment for optimal outcomesand reduced relapse risk (see Rosen et al., 1995;Veale, Gournay, et al., 1996). Case series (Neziroglu& Yaryura-Tobias, 1993) indicate that 20-session orlonger treatments are acceptable to patients, consis-tent with our clinical experience. For these reasons,two different treatment durations were used in orderto explore whether 18 sessions were sufficient orwhether four additional sessions appeared to increasetreatment outcome or was more acceptable topatients. Therapeutic progress and related symptoms(e.g., mood) were assessed at baseline and posttreat-ment using measures described below. Symptomswere assessed again at 3- and 6-month follow-upassessments.

Safety ProceduresGiven the high rates of suicidality and morbidity inBDD, the following procedures were in place toassess and manage suicidality and clinical deteriora-tion. Screening procedures excluded potential sub-jects who would require a higher level of care. Oncepatients started treatment, therapists were availablebetween sessions if necessary to discuss any safetyconcerns. Psychiatric emergency rooms at both siteswere available at all times. The Beck DepressionInventory (BDI-II; Beck, Steer, & Brown, 1996) wasadministered weekly for clinical purposes to monitordepression and suicidality; any participant with ascore N1 on the suicide item (#9) at any visit wasimmediately evaluated by the therapist to determinewhether a higher level of care was clinicallyindicated. In addition, we monitored for clinicaldeterioration, as defined by three consecutive Clin-ical Global Impression Scale (CGI; Guy, 1976)ratings of 6 (much worse) or 7 (very much worse).

TreatmentThe main components of the manualized treatmentprotocol are described below and are available inWilhelm et al. (in press).

core treatment components

Psychoeducation and Case FormulationBased on the information obtained during the as-sessment, the therapist and patient together derived acognitive–behavioral model for the patient's specificBDD symptoms, including hypothesizedmechanismsthat were causing and/or maintaining the symptoms.

Cognitive RestructuringCognitive techniques included Socratic questioningto evaluate maladaptive thoughts, completingthought records, identifying cognitive errors, apply-ing the downward arrow technique, and identifying

628 wilhelm et al .

and evaluating advantages and disadvantages ofholding BDD-related beliefs and behaviors.

Exposure and Ritual PreventionAfter identifying avoidance behaviors (e.g., socialsituations, work or school, physical activities), thetherapist and the patient developed an exposurehierarchy of situations that provoked anxiety ordiscomfort (e.g., social activities such as attendingfamily gatherings, work situations, or situationsthat exposed body parts to others, such as leavingthe house without sunglasses or a hat). To reduceritualistic behaviors like excessive mirror checking,participants monitored the frequency and contextsin which they performed their rituals, and identifiedstrategies to resist them. Behavioral experiments inwhich patients tested a particular hypothesis (e.g.,“I will be mocked if I attend class looking like this”)were often designed before assigning the situationas an exposure and ritual prevention exercise. Afterthe experiment the patient and therapist determinedwhether the original predictions were accurate andwhat conclusions could be drawn based on theoutcome of the experiment.

Mindfulness/Perceptual RetrainingRecent findings in cognitive neuroscience suggestthat BDD patients overfocus on details of visualstimuli (e.g., Deckersbach et al., 2000; Feusner,Moller, et al., 2010; Feusner, Moody, et al., 2010;Feusner et al., 2007). This is consistent with clinicalobservations. When BDD patients look at theirreflection in the mirror, they usually focus selectivelyon the body parts of concern, while ignoring otherbody parts. Perceptual retrainingwas combinedwithmindfulness skills to help patients learn to “see thebig picture” and to attend to aspects of appearanceother than the perceived defects. Patients learned toobserve and describe their entire bodywhile standinganormal distance (e.g., 3 feet) from themirror, ratherthan a few inches away. Instead of using harshlanguage, such as “Look atmy bug-eyes! I look like afreak!” patients learned to describe their appearanceusing objective, nonjudgmental language (e.g., “Myeyes are brown and round”). Patients were alsoasked to refrain from engaging in “appearance-fixing” behaviors while in front of the mirror. Inaddition, patients learned to retrain their attentionwhen interacting with other people; rather than justcomparing their disliked body parts to the same bodyparts of others, they learned to pay attention to otheraspects of appearance and nonappearance charac-teristics of others, as well as their surroundings.

Advanced Cognitive StrategiesAs patients made progress on negative thoughts andintermediate beliefs about their appearance, thera-

pists helped them identify and modify deeper-level(core) beliefs such as “I am worthless” or “I amunlovable.” Patients learned how to broaden thebasis of their self-worth to include factors other thanappearance (e.g., talents, intelligence, moral values).

Relapse PreventionThroughout the treatment and, in particular, duringthe last sessions, patients learned to schedule healthyactivities (e.g., hobbies, a volunteer job) to replaceBDD-related repetitive behaviors. During relapseprevention, therapists helped patients prevent,expect, and react effectively to setbacks, and taughtpatients to conduct self-therapy sessions.

Modular InterventionsIn addition to the strategies described above, thetreatment protocol included flexible treatment mod-ules that therapists selected as needed according toeach patient's individual symptoms. This approachensured that the treatment was tailored to problemareas that are characteristic of some but not allpatients (Eifert, Schulte, Zvolensky, Lejuez, & Lau,1997). Modules focused on (a) skin picking and hairplucking: This module uses habit reversal forcompulsive skin picking and hair pulling, whichmore than one-third of BDD patients engage in to tryto improve their appearance (Grant, Menard, &Phillips, 2006; Phillips & Taub, 1995). Manypatients consider skin picking, which can be medi-cally dangerous (O'Sullivan, Phillips, Keuthen, &Wilhelm, 1999), one of their most distressing symp-toms. (b)Muscularity and shape/weight module: Thismodule is most often used for patients (mostly males)with muscle dysmorphia, a particularly malignantformof BDDassociatedwith anabolic steroid abuse inwhich patients think they are insufficiently big andmuscular (Pope, Gruber, Choi, Olivardia, & Phillips,1997; Pope, Phillips, & Olivardia, 2000; Pope et al.,2005). Thismodule is also used for patientswho thinkthey are too fat (although patients with primaryweight concerns were excluded from the study).(c)Cosmetic treatment module: This module containspsychoeducation for patients who are consideringcosmetic treatment (e.g., surgical, dermatologic) forBDD symptoms. A majority of BDD patients receivecosmetic treatment for their perceived appearanceflaws; however, cosmetic treatments do not appeareffective for BDD (Phillips, Grant, Siniscalchi, &Albertini, 2001). Cognitive and motivational strate-gies are used to address maladaptive beliefs about theperceived benefits of surgery as well as to enhancepatients’ engagement in CBT. (d)Mood managementmodule: This module includes activity scheduling andother approaches for more severely depressedpatients. Treatment also included a motivational

1 Although two patients terminated early, one completed most ofthe posttreatment interview assessment. Therefore, the last observa-tion carried forward approach affected only one patient who hadmissing data at the posttreatment visit. A sensitivity analysis excludingthis patient yields virtually identical results, t(10)=5.10, pb0.001,d=3.40.

2 Effect size d for paired comparisons, calculated with correctionfor small sample bias as d=g[1– (3/(4(n–1)–1)], where g=Mpre–Mpost/SDpre (Becker, 1988).

3 The same patients who met the criterion for response based ona ≥30% change in the BDD-YBOCS also met the criterion forreliable change based on the reliable change index (Jacobson &Truax, 1991).

629modular cbt for body dysmorphic disorder

interviewing module to be used whenever patientsexhibited ambivalence about starting treatment or toenhance motivation as needed during the course oftheir treatment.

measures

All participants were interviewed before and aftertreatment, as well as during the follow-up phase, bya doctoral-level independent evaluator. Participantswere assessed with the following measures beforeand after treatment.

Yale-Brown Obsessive Compulsive Scale Modifiedfor BDDThe BDD-YBOCS is a reliable and valid 12-itemsemistructured clinician-administered scale that ratescurrent severity of BDDsymptoms.TheBDD-YBOCSwas the primary outcome measure. A reduction inBDD-YBOCS score of 30% or greater, an empiricallybased cut point, was selected a priori to designateresponse to treatment (Phillips et al., 1997).

Clinical Global Impression ScaleThe CGI (Guy, 1976) is a widely used measure thatprovides a global rating of change in overall symp-toms; scores range from 1 (very much improved) to7 (verymuchworse). A score of 1 or 2 (much or verymuch improved, respectively) was considered toconstitute response to the treatment. The CGI wasalso administered weekly for clinical purposes toassess for clinical deterioration.

Brown Assessment of Beliefs ScaleThe Brown Assessment of Beliefs Scale (BABS; Eisenet al., 1998) is a reliable and valid 7-item semistruc-tured clinician-administered interview that was usedto assess delusionality of BDD beliefs (e.g., “I amhideous looking”). The BABS assesses insight/delu-sionality dimensionally and also categorizes beliefs asdelusional or nondelusional; the cut point for thepresence of delusional thinking is a total BABS score≥18 plus a score of 4 on item 1 (conviction). On thisscale, 3 of 12 patients (25%) had delusional BDDbeliefs at study baseline.

Beck Depression InventoryParticipants also completed the BDI-II (Beck et al.,1996), a reliable and valid 21-item self-report mea-sure of depression severity with items that reflectDSM-IV criteria for major depressive disorder. TheBDI-II was also administered weekly for clinicalpurposes to monitor depression and suicidality.

Client Satisfaction InventoryPatients’ satisfaction with clinical services receivedwas assessed at each visit using theClient Satisfaction

Inventory (CSI; McMurtry & Hudson, 2000). TheCSI is a 25-item reliable and valid self-reportquestionnaire that yields a measure of satisfactionwith treatment ranging from 0 to 100% satisfied.

ResultsData were analyzed with the Statistical Package forthe Social Sciences, version 17.0. Analyses for con-tinuous variableswere performed using paired t tests,which enable presentation of data from this smallstudy in a simple manner, devoid of some of theassumptions needed for HLM (e.g., linear or para-metric change over time); normality was upheld evenin this small sample. The primary analyses wereintention to treat; these analyses included the fullsample of 12 patients who had at least one treatmentsession.When posttreatment data weremissing, datawere carried forward from the last assessmentcompleted. Secondary analyses were also conducted,using data only from the 10 treatment completers.The dependent variables reflected changes in out-come from baseline. We performed paired t tests toexamine whether patients maintained their post-treatment gains at 3- and 6-month follow-up. Alltests were two-tailed. An alpha level of .05 was usedto determine statistical significance.Means and standard deviations on the outcome

measures at pretreatment and posttreatment arepresented in Table 1. Mean BDD symptom severityat initial evaluation was moderate to severe. Scoreson the BDD-YBOCS decreased significantly for boththe intention-to-treat and the completer samples(intention to treat, t(11)=5.41, pb .001, effect sized=3.351; completers, t(9)=6.08, pb .001, effect sized=3.82).2 On the BDD-YBOCS, 75%of those in theintention-to-treat sample were responders, and 80%of completerswere responders.3 Themeanpercentagedecrease on the BDD-YBOCS for the intention-to-treat sample was 47.1% (SD=32.2); for completers itwas 53.0% (SD=30.8). On the CGI, 75% of theintention-to-treat sample and 80% of completerswere responders.

4 BDI-II data are missing for one patient.

Table 1Means and Standard Deviations on Outcome Measures at Pretest and Posttest

Measure Pretreatment Posttreatment Posttreatment 3-monthfollow-up

6-monthfollow-up

Intention-to-treatsample

Completersample

Completersample

Completersample

(n=12) (n=12) (n=10) (n=10) (n=9)

Yale-Brown Obsessive-Compulsive ScaleModified for BDD (BDD-YBOCS)

32.9(4.1) 18.1(11.7) 16.0(10.7) 15.2(10.3) 17.0(10.5)

Beck Depression Inventory (BDI-II) 22.9(13.2) 15.8(16.2) 12.4(14.6) 11.8(15.3)a 11.8(16.7)Brown Assessment of Belief Scale (BABS) 14.7(4.7)b 10.8(7.5)c 10.1(7.2)c 8.7(7.3) 9.0(7.1)

Note.an=9 due to missing data.bReflects poor insight.cReflects fair insight.

630 wilhelm et al .

BDI scores also decreased significantly (intentionto treat, t(11)=2.21, p= .049, effect size d=.50;completers, t(9)=3.23, p= .01, effect size d=.82).Improvement in insight of BDD beliefs, as measuredby the BABS, occurred at a trend level (intention totreat, t(11)=1.87, p= .09, effect size d=.76; com-pleters, t(9)=2.06, p= .07, effect size d=.86).Of the 12 patients who received at least one

treatment session, 10 (83%) completed all treatmentsessions. One patient terminated treatment earlybecause of severe depression and lack of motivationto complete homework assignments, and onereported that he did not want to give up his BDD-related repetitive behaviors because he was afraidthat his appearance would worsen substantially if hewere to even slightly decrease these behaviors.Satisfaction with treatment length (18 or 22

sessions) was determined qualitatively posttreatmentbased on an interview with the patient and thetherapist; because of the small sample size, statisticalcomparisons of outcomes in these two groups werenot conducted. Based on patient and clinician feed-back, participants who were assigned to 18 sessionswished the treatment had been longer because theyfelt they could continue to benefit from treatment.Patients who had been assigned to 22 sessions werepleased that their treatment was not shorter. Themean posttreatment CSI score was 88.94% (SD=10.97), suggesting that patients were highly satisfiedwith the treatment provided.All patients who completed treatment provided

3-month follow-up data; 9 of the 10 provided6-month follow-up data. Paired t tests revealed thatBDD-YBOCS scores did not change significantlyfromposttreatment to 3-month follow-up, t(9)= .811,p=.438, d=0.07, or from posttreatment to 6-monthfollow-up, t(8)=−.39, p=.707, d=0.04. Similarly,BABS scores remained stable between posttreatmentand 3-month follow-up, t(9)= .68, p=.513, d=0.17,and between posttreatment and 6-month follow-up,

t(8)= .27, p=.797, d=0.07. BDI scores also remainedstable between posttreatment and 3-month follow-up, t(8)

4 = .87, p=.409, d=0.12, and from posttreat-ment to 6-month follow–up, t(8)=−.26, p=.798, d=−0.03. According to the CGI, 80% of completerswere responders at 3- and 6-month follow-up.

DiscussionResults from this pilot study suggest that our mod-ular manualized CBT treatment for BDD is feasibleto implement and appears to be an effective treat-ment for patients with this disorder. Mean BDDsymptom severity scores improved frommoderatelysevere to the subclinical range, and depressivesymptoms significantly improved from moderateto mild. In addition, delusionality decreased by26%. While improvement on the BABS indicated achange frompoor to fair insight at a trend level (mostlikely due to the small sample size), the effect size waslarge. Our relatively high retention rate suggests thatthis intervention is acceptable to most patients, asmore than 80% of those who began treatmentcompleted it. Moreover, follow-up data showed thatpatients who completed treatment maintained theirgains for at least 6 months following treatmentcompletion. In addition, patients reported very highlevels of satisfaction with the treatment (88.9%)based on the CSI.The modular manualized treatment that we

developed has the advantages of all manual-basedtreatments (e.g., replicable, standardized techniquesthat can be used to enhance training and dissem-ination; Addis, 1997; Wilson, 1996). Standardtreatment manuals have been criticized for limitingtherapist creativity and flexibility (e.g., Strupp &Anderson, 1997). A modular approach providesthe flexibility to personalize a treatment to address

631modular cbt for body dysmorphic disorder

important symptoms that are characteristic of somebut not all patients (Eifert et al., 1997). Thus,modularized treatment provides a structured flex-ibility, whereby treatment procedures can be usedflexibly and tailored to an individual patient's needswhile ensuring that core procedures are deliveredwith a high level of fidelity (e.g., Chorpita, 2007).One study limitation is the small sample size,which

limited statistical power and may have led to Type IIerror. As Kraemer, Mintz, Noda, Tinklenberg, andYesavage (2006) point out, small pilot studies canresult in effect sizes with wide confidence intervals,and therefore it is important to consider that suchstudies are more useful as a proof of conceptapproach than as a means to obtain reliable efficacyestimates. Another limitation is the large number ofindividuals whowere screened but did not qualify forthe study, potentially limiting the generalizability ofthese findings. However, the most common reasonindividuals were excluded was that they did not meetdiagnostic criteria for BDD. In addition, given thatthis study is to our knowledge the first study of amanualized modular psychosocial treatment forBDD, we chose to use standard inclusion/exclusioncriteria for efficacy trials. Study inclusion/exclusioncriteria were broader than inmost previous studies ofCBT for BDD. Another potential limitation is thatthis treatment may not be appropriate for BDDpatients who are actively suicidal, as this was anexclusion criterion (although individualswith passivesuicidal ideation were included). Suicidal ideation,suicide attempts, and completed suicide are majorproblems in BDD and thus far have received littleattention in treatment studies due to the exclusion ofactively suicidal patients for safety reasons. Futuretreatment studies may need to be specifically tailoredto address suicidality in BDD. In addition, at thisinitial stage of treatment development and testingtherapists were senior clinicians with expertise inBDD, so it is not clear whether comparable resultswill be achieved by less experienced clinicians. Thus,research is needed to test the treatment to determinewhether it could be successfully applied by nonexperttherapists. Finally, this pilot study did not include acontrol condition that would enable us to comparethe degree of improvement observed over the courseof treatment with improvement that might beexpected simply due to the passage of time orregression to the mean. However, given the well-documented chronicity of BDD (Phillips, Pagano, etal., 2006), it is unlikely that we would obtain such ahigh improvement rate over the course of 24 weeks.Given the uncontrolled nature of the study, it is alsopossible that patients could have responded to thenonspecific elements of the therapy (e.g., therapistattention); however, this is also unlikely, given the

severity and complexity of BDD symptoms. Thus, thepromising results of this open trial require follow-upwith controlled trials in larger samples in which theefficacy of CBT for BDD is examined compared towait-list, treatment as usual, or alternative treatmentconditions. Given that BDD is an understudied,severe, and common disorder for which efficacioustreatment options are currently very limited, suchstudies are greatly needed.

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