BEHAVIOR THERAPY 27, 67-77, 1996

Effect of Cognitive Behavior Therapy on Persons With Body Dysmorphic Disorder and

Comorbid Axis II Diagnoses

FUGEN NEZIROGLU

DEAN McKAY

JOHN TODARO

JOSE A. YARYURA-TOBIAS

Institute for Bio-Behavioral Therapy and Research

A study was conducted to determine the effect of intensive cognitive behavior therapy on body dysmorphic disorder (BDD) and to investigate the presence of comorbid personality disorders in this population. Seventeen patients diagnosed with BDD par- ticipated. They all received 4 weeks of daily 90-min sessions of cognitive behavior therapy. During treatment they were exposed to their perceived physical defect and prevented from engaging in behaviors that reduce their discomfort. The majority of the patients were preoccupied with their nose and complexion, and, consequently, they frequently checked their defective body parts, looked in the mirror, and avoided social interaction. At the end of treatment there was a significant decrease in their preoccupation and time engaged in the above behaviors. As for the personality dis- orders, the mean number of personality disorders was 6. The most common per- sonality disorders were avoidant, obsessive compulsive, borderline, self defeating, and dependent.

In the past few years there has been growing interest in the obsessive com- pulsive spectrum disorders. One of the spectrum disorders to receive attention is body dysmorphic disorder (BDD), which is characterized by an excessive preoccupation with an imagined bodily defect. Symptoms of BDD are present in a variety of disorders. It is reported in depression (Cotterill, 1981; Hardy & Cotterill, 1982), psychosis (Connolly & Gibson, 1978; Crisp, 1981; Hay, 1970; Korkina, 1959; Stekel, 1950), obsessional states (Hardy & Cotterill; Janet, 1908; Morselli, 1886; Stekel), obsessive compulsive disorder (OCD;

Portions of this data were presented at the 28th Annual Convention of the Association for Advancement of Behavior Therapy, San Diego, CA.

Correspondence should be addressed to Fugen Neziroglu, 935 Northern Boulevard, Suite 102, Great Neck, NY 11021.

67 0005-7894/96/0067-007751.00/0 Copyright 1996 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

6 8 NEZIROGLU ET AL.

Hollander, Leibowitz, Winchel, Klumker, & Klein, 1989; Jenike & Baer, 1990; Neziroglu & Yaryura-Tobias, 1991, 1993a, 1993b), and anorexia nervosa (Jerome, 1987; Thomas, 1984).

Several researchers suggest that individuals with BDD have various personality disorders (Andreason & Bardach, 1977; Braddock, 1982; Edgerton, Jacobson, & Meyer, 1960; Hay, 1970). As early as 1908, Janet described BDD as being rooted in the personality, resembling hysterics and obsessives. Dietrich (1962) believed that, although BDD may occur in a variety of illnesses, the syndrome usually arises out of neurotic conditions or crises of personality development. Hay compared patients with BDD to a control group and found that patients were more "obsessoid, introverted, intropunitive, highly neurotic and hostile" (p. 401) as compared to the control group. He concluded that BDD occurs in insecure and sensitive personalities. Andreasen and Bardach concurred with Hay in concluding that the underlying factor of BDD is a moderate to severe disturbance in personality, typically schizoid or obsessional in nature. Per- sonality disorders have been reported in adolescents as young as 13 years of age (Korenblum, Marton, Golombek, & Stein, 1990).

The literature suggests that there is a relationship between BDD and per- sonality disorders. Whether BDD is a symptom often seen in personality disorders or a separate entity, as in the Diagnostic and Statistical Manual of Mental Disorders (DSM Ill-R; American Psychiatric Association, 1987) and DSM IV with accompanying personality disorders, is still undecided.

It has been proposed that BDD is a variant of OCD (Hollander & Phillips, 1993; Neziroglu & Yaryura-Tobias, 1993a, 1993b). Comparisons between OCD and BDD patients reveal similar MMPI profiles, and similar behavioral and pharmacological approaches are reported to be effective (Neziroglu & Yaryura- Tobias, 1993a). However, BDD patients seem to have significantly more de- pression and higher levels of overvalued ideas (Neziroglu, McKay, & Yaryura- Tobias, 1993) and may be delusional.

The few case reports suggest that behavior therapy may be effective in reducing BDD symptoms (Braddock, 1982; Jerome, 1987; Marks & Mishan, 1988; Neziroglu & Yaryura-Tobias, 1993b). In most of these studies, ex- posure and response prevention (ERP) was used, whereby patients were exposed to their perceived physical "defects" and prevented from engaging in their compulsions, i.e., exposing BDD patients to others without camou- flaging their "defects" and preventing them from checking their faces in the mirror or seeking reassurance. However, most of these studies were limited in number of patients, and duration of treatment varied from patient to patient.

Since the advent of DSMIII-R, when BDD was first included as a diagnostic category, the presence of Axis II diagnoses in this population has not been assessed. The purpose of this pilot study is to investigate the efficacy of cog- nitive behavior therapy among patients with BDD and to identify the frequency of personality disorders in this population.

EFFECT OF CBT ON BDD 69

Method Patients

Seventeen patients diagnosed as BDD according to DSM III-R participated in this study. Patients were independently assessed by a psychologist and a psychiatrist, and there was complete diagnostic agreement in each case. In addition, the diagnosis was confirmed at an interdisciplinary staff meeting. There were 10 females and 7 males, ages ranging from 15 to 45, with a mean age of 25,1 (SD = 10.3) years. The mean duration of their illness was 9.2 years (SD = 6.1). The mean age of onset was 16.7 years (SD = 4.8). The percentage of the sample concerned with various body parts were nose (47 %), complexion (41%), eyes (35%), stomach (29%), hairline (29%), buttocks (24%), legs (18%), teeth (12%), genitals (12%), and mouth (6%). The behaviors that patients engaged in to undo their preoccupation with the body parts were checking body part (88%), mirror checking (82%), avoiding others (82%), makeup rituals (65%), avoiding mirrors (29%), face picking (18%), and checking room lighting (6%).

Materials and Apparatus

Yale-Brown Obsessive Compulsive Scale for Body Dysmorphic Disorder. Severity of BDD symptoms was assessed with a modified version of the Yale- Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989). The Yale-Brown Obsessive Compulsive Scale for Body Dysmorphic Disorder (YBOCSBDD; Hollander, 1991) was adapted from the first 10 items of the Y-BOCS and, like the Y-BOCS, it yields three scores: Obsessions, Compul- sions, and Total. The Obsessions and Compulsions Scales each assess five dimensions that are typically distressing to patients: frequency, social and work interference, anxiety or distress, resistance, and control over obsessions and compulsions. For BDD, each of these items was slightly revised to reflect excessive concern with perceived ugliness or defects in affected body parts. The Y-BOCSBDD appears to have an acceptable frequency of endorsements and range of severity for each item, correlation of individual items with the "total score, and internal consistency (K. Phillips, personal communication, June 5, 1995).

Structured Clinical Interview for DSM III-R Personality Disorders is a ll9-question structured interview designed to diagnose all of the personality disorders defined in DSM III (SCID-II; Spitzer, Williams, Gibbon & First, 1990). These are cluster A (avoidant, dependent, obsessive compulsive), cluster B (narcissistic, histrionic, borderline), and cluster C (paranoid, schizoid, schizo- typal, antisocial). In addition to these 10 categories, two personality dis- orders currently under investigation are assessed: passive aggressive and self defeating.

A test-retest reliability study of 103 patients indicated that weighted kappas ranged from. 24 for obsessive compulsive personality disorder to .74 for histrionic personality disorder, with an overall weighted kappa of .53 (First et al., in

70 N E Z I R O G L U ET AL.

press). Interrater reliability for the cross-site cases did not differ appreciably from that for the same site cases. The weighted kappa was .43 for the cross site and .48 for same site. Mean duration of administration time of the SCID-II is 36 rain. In the same study, diagnostic validity as determined by the asso- ciation of SCID-II results with the general functioning of the patient (GAF) indicated that the GAF was lower in patients with, as compared to without, personality disorder. In another validity study comparing the SCID-II to the Personality Disorder Examination, the kappas ranged from .14 to .66 (Oldham et al., 1992). The assessors of the SCID-II were specifically trained by experts in its administration.

Procedure

The YBOCSBDD was administered at pre- and posttest and the SCID-II at pretest. After these measurements, cognitive behavior therapy was initi- ated. Behavior therapy consisted of ERP. ERP was aimed at exposing patients to their perceived physical defects and preventing them from engaging in com- pulsions. Cognitive therapy was aimed at challenging patients' faulty beliefs about their appearance (e.g., I must be perfect, I must be noticed, I am ex- tremely ugly, my nose is very big). Patients received 4 weeks of intensive behavior therapy consisting of 90-min sessions five times a week. Sessions were divided into 60 rain of ERP and 30 min of cognitive therapy.

Results Of the 17 patients, 12 (70.6%) had YBOCSBDD scores change by more

than 50% at posttreatment, indicating improvement with cognitive behavior therapy. Across all subjects, a matched pairs t test indicated a significant dif- ference from pre- to posttest (t,6) --- 6.40, p < .001; Mp~et,,, YBOCSBDD = 25.7, Mposttest VBOCSBDD = 12.0). At posttest, 5 of 17 patients still had YBOCSBDD scores that were clinically significant, indicating the presence of OCD symptoms.

The entire patient sample met criteria for at least one, and often several, personality disorder. Thirteen of 17 patients (76.5%) had four or more Axis II diagnoses. The mean number of personality disorders diagnosed was 6.0. A case by case breakdown of patient data is presented in Table 1. No discern- able relationship could be established between number of personality disorders presented at pretest and treatment outcome.

As shown in Table 2, the most prevalent personality disorders were avoidant, obsessive compulsive, borderline, self defeating, and dependent. Fully 94% of the subjects had personality disorders from cluster C (avoidant, dependent, and OC).

As diagnosed independently by a psychologist and psychiatrist according to DSM Ill-R, the following comorbid conditions were found: OCD (94% of subjects), mood disorder (71%), social phobia (18%), generalized anxiety disorder (6%), posttraumatic stress disorder (6%), substance abuse (6%), and oppositional defiant disorder (6%).

TABLE 1 Y-BOCSBDD SCORES PRE- TO POSTTREATMENT AND AXIS II DIAGNOSES

Patient

Y-BOCSBDD Personality

Age Diagnoses Pretest Posttest % Change

1 20 Avoidant 27 24 11.1 OC Paranoid Histrionic Narcissistic Borderline SD

2 28 Avoidant 26 10 61.5 Dependent OC Paranoid Histrionic Borderline SD

3 15 Dependent 25 5 80.0 OC PA SD Narcissistic Borderline

4 38 Narcissistic 27 25 7.4 5 21 Dependent 22 7 68.2

Avoidant OC PA SD Paranoid Narcissistic Borderline

6 40 Dependent 20 6 70.0 Avoidant SD Narcissistic

7 16 Avoidant 22 9 54.5 Dependent OC SD Histrionic Paranoid Narcissistic Borderline

8 28 Avoidant 24 11 54.2 9 39 Avoidant 37 4 89.2

Dependent OC SD Paranoid Schizoid Histrionic Narcissistic Borderline

10 34 Avoidant 27 25 7.4 OC SD Paranoid Borderline

(continued)

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TABLE 1 (continued)

Patient

Y-BOCSBDD Personality

Age Diagnoses Pretest Posttest % Change

11 17 Avoidant 26 11 57.7 Dependent OC SD Schizotypal Histrionic Narcissistic Borderline Antisocial

12 20 Avoidant 24 3 87.5 Dependent OC

13 39 Avoidant 28 14 50.0 OC Dependent SD Borderline

14 20 Avoidant 22 2 90.1 Dependent OC PA SD Paranoid Schizotypal Borderline Antisocial

15 20 Avoidant 26 12 53.8 Dependent OC Schizotypal Histrionic Narcissistic Borderline

16 34 Avoidant 34 28 17.6 OC SD Paranoid Borderline Antisocial

17 33 Avoidant 33 19 46.7 Dependent OC SD Paranoid Histrionic Borderline

Note. OC: Obsessive Compulsive Personality; SD: Self Defeating Personality; PA: Passive Aggressive Personality; positive treatment outcome is defined by improvement of more than 50% at posttest on the YBOCSBDD. Client #11 was technically too young to receive a diagnosis of antisocial personality disorder.

EFFECT OF CBT ON BDD

TABLE 2 PERCENTAGES OF AXIS II DIAGNOSES AMONG BODY DYSMORPHIC DISORDER PATIENTS

73

Personality Disorder Percentages

Avoidant 82 Obsessive Compulsive 82 Borderline 76 Self Defeating 76 Dependent 71 Narcissistic 53 Paranoid 53 Histrionic 47 Passive Aggressive 18 Schizotypal 18 Antisocial 18 Schizoid 6 None 0

n = 17.

Discussion The present study suggests that cognitive behavioral therapy may be effec-

tive for the treatment of BDD, corroborating previous findings (Marks & Mishan, 1988; Neziroglu & Yaryura-Tobias, 1993a, 1993b; Rosen, Reiter, & Orosan, 1995). At the end of 4 weeks of intensive treatment, patients showed consid- erable lessening in their preoccupation with their perceived physical defect and in the amount of time they engaged in behaviors to reduce their obses- sions. However, this preliminary study lacked a control group and, therefore, changes in BDD symptoms cannot be totally ascribed to treatment. There has been very little data-based research available on BDD, and this study did provide some evidence of improvement.

In addition to the positive treatment response, a high comorbidity between BDD and Axis II disorders was found. It appears that BDD patients often have several personality disorder diagnoses. Over 75% of the patients had more than four Axis II diagnoses with an average of six personality disorders. The high comorbidity between BDD and personality disorders does not mean that BDD arises out of personality disturbance. Axis II diagnoses are noted in other Axis I diagnoses (Black, Bell, Hulbert, & Nasrallah, 1988; Joffee, Swinson, & Regan, 1988; Mavissakalian & Hamann, 1987; Pfohl, Stangl, & Zimmerman, 1984; Reich, Noyes, & Troughton, 1987).

The high rate of comorbidity as assessed by the SCID-II may be attributed to several factors. First, the SCID-II may be too sensitive- unable to discrimi- nate between personality characteristics and thus overdiagnosis occurs. How- ever, other researchers using different assessment instruments for personality disorders have obtained similar findings (Baer et al., 1990; Baer & Jenike, 1992; Joffe, Swinson, & Regan, 1988; Oldham et al., 1992). They also report

74 N E Z I R O G L U ET AL.

several personality disorders, often as many as four or more in any given Axis I diagnosis.

Second, in this study a high comorbidity between BDD and OCD was noted (94%). It is reported that more than 50% of patients with OCD also meet criteria for one or more personality disorders (Mavissakalian, Hamann, & Jones, 1990). Therefore, the high percentage of Axis II diagnoses noted in this study may not be due to the sensitivity of the SCID-II but may be a func- tion of OCD in a BDD population.

Third, it seems that Axis II diagnoses may be an outgrowth of Axis I diag- noses. In other words, BDD presents a great variety of symptoms, i.e., obsessions, compulsions, anxiety, depression, ideas of reference, and isola- tion. Axis II symptoms may be similar to Axis I and, therefore, the assess- ment instruments may be tapping into Axis I symptomatology. If this hy- pothesis is correct, then the classification of personality disorders should be reformulated.

Fourth, there may be an overlapping of symptoms not only between Axis I and Axis II diagnoses, but among the Axis II diagnoses themselves. In a pre- vious study, substantial overlapping occurred among personality disorders, and the authors suggested that the categorical distinctions among the personality disorders may be illusory (Oldham et al., 1992).

A high comorbidity between BDD and OCD (94%) may suggest that BDD is a variant of OCD (Hollander et al., 1989; Hollander & Phillips, 1993; Neziroglu & Yaryura-Tobias, 1993a, 1993b). There seems to be some differ- ences between the two disorders in terms of the relationship between num- ber of personality disorders and treatment outcome. In OCD, the greater the number of personality disorders, the poorer the treatment outcome (Baer et al., 1992). For BDD, there was no relationship between the number of per- sonality disorders and the YBOCSBDD score at the end of treatment nor with the amount of change on the YBOCSBDD. Perhaps the difference between the two populations may be attributed to the greater number of cluster A per- sonality disorders noted within the OCD population, as compared to the BDD population, in this study, rather than merely the number of Axis II diagnoses.

Most of the patients in this study had Axis II diagnoses from cluster C (avoidant, dependent, and obsessive compulsive). The next most frequently observed diagnoses were from cluster B (narcissistic, histrionic, antisocial, and borderline). A little over one-half the patients presented with diagnoses from cluster A (paranoid, schizoid, and schizotypal), which has been reported to be a predictor of poorer treatment outcome for OCD (Jenike, Baer, Minichiello, Schwartz, & Carey, 1986; Minichiello, Baer, & Jenike, 1987; Stanley, Turner, & Borden, 1990). Both clusters B and C were found to be inadequate predictors of treatment outcome for obsessive compulsive patients (Baer et al., 1992). Personality characteristics for these two clusters do not seem to impact treatment outcome. The only significant predictor is from cluster A. Perhaps because the patients of this study had primarily Axis II

EFFECT OF CBT ON BDD 75

diagnoses from clusters B and C, there was no discernable relationship be- tween type of personality disorder and treatment outcome.

The behaviors of patients with BDD may be described as bizarre, odd, and suspicious, because they engage in mirror checking and camouflaging, are isolative, and have ideas of reference, i.e., believing others are looking at them. Despite these behaviors and cognitions, patients do not frequently exhibit cluster A, Axis II symptoms, which are associated with these traits. Further research is needed to determine why bizarreness in OCD is associated with cluster A personalities, but bizarreness in BDD is not.

In summary, ERP with cognitive therapy appears to be effective in reducing the preoccupation with perceived defect and associated behaviors. Further studies may examine the differential effect of behavior and cognitive therapy. In addition, patients with BDD appear to have several comorbid personality disorders. Typically, these are obsessive compulsive, dependent, borderline, and self defeating. Future research may investigate prognostic variables, such as pretreatment, number and type of personality disorders, and outcome. Finally, the effect of behavior therapy on personality disorders at posttreatment and follow-up would contribute to the understanding of the relationships between Axis I and Axis II diagnoses.

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RECEIVED: June 26, 1995 ACCEPTED: August 10, 1995