Study of Patients With Body Image Issues Treated With 2 Different Behavioral Interventions
| Status: | Recruiting |
|---|---|
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 4/2/2016 |
| Start Date: | April 2007 |
| Contact: | Eda Gorbis, PhD, LMFT |
| Email: | edagorbis@yahoo.com |
| Phone: | 310-443-0031 |
Crooked Mirror Externalization Therapy for Body Dysmorphic Disorder
Body Dysmorphic Disorder (BDD) is a disabling condition that until recently has been largely
ignored. Sufferers of BDD worry excessively and unreasonably about some flaw in their
appearance that may be minimal or even nonexistent. These internalized body image
distortions prompt sufferers to constantly check the perceived defects in mirrors, seek
reassurance of their images from others, obtain unnecessary cosmetic and/or dermatological
procedures, and even conduct self-surgeries. These obsessive concerns and compulsive
behaviors cause significant emotional distress and often significantly interfere with global
functioning. Currently, cognitive-behavioral therapy (CBT) in conjunction with
psychopharmacology is the preferred treatment for BDD. In addition, two relatively new
exposure techniques ("mirror retraining method" and "crooked mirror externalization
therapy") that utilize mirrors to exaggerate the patient's imagined defect appear to
increase the benefits of CBT. However, the treatment efficacies of these relatively novel
methods have not been rigorously tested or methodologically compared. Although six out of
seven patients treated with crooked mirror externalization therapy at the Westwood Institute
for Anxiety Disorders, Inc. demonstrated significant gains, the small sample size does not
allow for any significant generalizations. Thus, the goals of this project are: 1) to
determine the efficacy of exposure therapy that utilizes mirrors in the treatment of BDD,
and 2) to evaluate the level of effectiveness of the mirror retraining method versus the
crooked mirror externalization therapy. To accomplish these goals, each subject taking part
in the study will do the following. They will go through an in-depth interview with the
study physician, Dr. Kagan, and complete several clinical assessment questionnaires to
confirm that they have BDD according to the Diagnostic and Statistical Manual of Mental
Disorders - Fourth Edition (DSM-IV). They will be assessed by the study independent
evaluator and complete several paper-and-pencil tests to determine the severity of the BDD
and if they have any cognitive difficulties. The subject will participate in 3 weeks of CBT
with either the mirror retraining method or the crooked mirror externalization therapy.
After the CBT, we will repeat the clinical assessment questionnaires and neurocognitive
testing. From the difference between the before and after scores on all these tests, we will
determine if there has been any change in the subject's BDD symptoms, and if so, the level
of effectiveness between the mirror retraining method and the crooked mirror externalization
therapy.
ignored. Sufferers of BDD worry excessively and unreasonably about some flaw in their
appearance that may be minimal or even nonexistent. These internalized body image
distortions prompt sufferers to constantly check the perceived defects in mirrors, seek
reassurance of their images from others, obtain unnecessary cosmetic and/or dermatological
procedures, and even conduct self-surgeries. These obsessive concerns and compulsive
behaviors cause significant emotional distress and often significantly interfere with global
functioning. Currently, cognitive-behavioral therapy (CBT) in conjunction with
psychopharmacology is the preferred treatment for BDD. In addition, two relatively new
exposure techniques ("mirror retraining method" and "crooked mirror externalization
therapy") that utilize mirrors to exaggerate the patient's imagined defect appear to
increase the benefits of CBT. However, the treatment efficacies of these relatively novel
methods have not been rigorously tested or methodologically compared. Although six out of
seven patients treated with crooked mirror externalization therapy at the Westwood Institute
for Anxiety Disorders, Inc. demonstrated significant gains, the small sample size does not
allow for any significant generalizations. Thus, the goals of this project are: 1) to
determine the efficacy of exposure therapy that utilizes mirrors in the treatment of BDD,
and 2) to evaluate the level of effectiveness of the mirror retraining method versus the
crooked mirror externalization therapy. To accomplish these goals, each subject taking part
in the study will do the following. They will go through an in-depth interview with the
study physician, Dr. Kagan, and complete several clinical assessment questionnaires to
confirm that they have BDD according to the Diagnostic and Statistical Manual of Mental
Disorders - Fourth Edition (DSM-IV). They will be assessed by the study independent
evaluator and complete several paper-and-pencil tests to determine the severity of the BDD
and if they have any cognitive difficulties. The subject will participate in 3 weeks of CBT
with either the mirror retraining method or the crooked mirror externalization therapy.
After the CBT, we will repeat the clinical assessment questionnaires and neurocognitive
testing. From the difference between the before and after scores on all these tests, we will
determine if there has been any change in the subject's BDD symptoms, and if so, the level
of effectiveness between the mirror retraining method and the crooked mirror externalization
therapy.
Screening: Potential subjects who call the Westwood Institute for Anxiety Disorders, Inc.
requesting treatment will be given details about the study by a trained research assistant.
Any questions that potential subjects have will be addressed. If subjects are interested,
they will be invited to be screened to determine whether they meet initial criteria for the
study. Potential subjects will be told that all information gathered during screening is
confidential. If a potential subject does not meet inclusion criteria, or decides not to
participate, the screening information will be destroyed. This information is then passed to
the study physician, Dr. Kagan, who will contact potential subjects to make an appointment
for further evaluation. Potential subjects are encouraged to discuss their possible
participation in this study with their physician, therapist, and/or family members. They are
also encouraged to write down questions they would like to ask the study physician upon
further evaluation. This screening process is done as part of the research process.
Further Evaluation: After the initial telephone screening, potential subjects will meet with
the principal investigator, Dr. Eda Gorbis, who will ask the subject to sign an informed
consent form (ICF). The research procedures and treatment will be described in detail to the
subject and any questions will be answered by the principal investigator. The ICF will be
signed by the subject and the principal investigator, agreeing to those procedures in the
study that are considered research, acknowledging that their participation is voluntary, and
that they have been informed of the risks and benefits of the study. Research procedures
include cognitive testing, standardized rating scales, and clinical assessment
questionnaires discussed below.
When the ICF is signed, the potential subjects will meet with the study physician, Dr.
Kagan, for a comprehensive psychiatric evaluation and physical assessment to confirm a
primary diagnosis of BDD according to the criteria of the Diagnostic and Statistical Manual
of Mental Disorders - Fourth Edition (DSM-IV), and identify any confounding comorbidity,
physical health, or medication issues which may or may not preclude their participation in
treatment. According to subjects' self-report, those who are currently on medication for
their BDD must have a regular prescribing physician who can continue prescribing their
medication.
Upon confirmation of inclusion into the study, subjects will then be given appointments for
cognitive testing and further clinical assessments by the study independent evaluator. The
Mini International Neuropsychiatric Interview for DSM-IV (M.I.N.I.; Sheehan & Lecrubier et
al., 1998) will be used to determine comorbid disorders that are excluded from the study,
which will take approximately 45 minutes to complete. The Wechsler Adult Intelligence Scale
- Third Edition (WAIS-III; Wechsler 1997), which is an instrument that assesses verbal and
nonverbal intellectual functioning, will be used to determine subjects' cognitive capacity,
and will take approximately 90-120 minutes to complete.
Assessment Instruments: One week prior to treatment, subjects will be administered a battery
of clinical rating scales and questionnaires to determine the severity of their BDD and any
secondary symptoms. This same assessment battery will be given immediately following
treatment to determine the level of efficacy of each of the two treatment groups. These
scales include the Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Body
Dysmorphic Disorder Examination-Self Report (BDDE-SR), BDD Diagnostic Module (BDDDM), Y-BOCS
Symptom Checklist, Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Hamilton Rating Scale for
Depression (Ham-D), Hamilton Anxiety Rating Scale (HARS), Fixity of Beliefs Questionnaire,
Global Assessment of Functioning (GAF), NIMH Global Obsessive-compulsive Scale, Brown
Assessment of Beliefs Scale (BABS), Obsessive-Compulsive Inventory (OCI),
Obsessive-Compulsive Rating Scale (OCON), Fear Survey Schedule (FSS), and the Revised
Willoughby Questionnaire. These will take approximately 90-120 minutes to complete.
Randomization: Following assessment, subjects will be pseudo-randomized into either the
mirror retraining treatment group or the crooked mirror treatment group.
Pseudo-randomization means that subjects will first be assigned to one of the two groups
randomly, then group membership will be remixed if needed to assure that there is no
significant between-group difference in pretreatment BDD-YBOCS scores. If possible, groups
will also be matched for age and gender.
Intensive Cognitive-Behavioral Therapy: After subjects complete the pre-treatment
assessments, the study therapist will meet with participants to design their treatment
program. Treatment will be conducted every day for 15 days, Monday through Friday, for
90-minute sessions. In addition, as a part of therapy, subjects will complete homework
assignments daily. Intensive CBT for BDD is done in the form of Exposure and Response
Prevention (ERP) with either the mirror retraining method or the crooked mirror
externalization therapy. This involves prolonged and repeated exposures to images of the
perceived defects, and prevention of ritualistic behavior (e.g., camouflaging with
cosmetics, skin-picking, etc.).
requesting treatment will be given details about the study by a trained research assistant.
Any questions that potential subjects have will be addressed. If subjects are interested,
they will be invited to be screened to determine whether they meet initial criteria for the
study. Potential subjects will be told that all information gathered during screening is
confidential. If a potential subject does not meet inclusion criteria, or decides not to
participate, the screening information will be destroyed. This information is then passed to
the study physician, Dr. Kagan, who will contact potential subjects to make an appointment
for further evaluation. Potential subjects are encouraged to discuss their possible
participation in this study with their physician, therapist, and/or family members. They are
also encouraged to write down questions they would like to ask the study physician upon
further evaluation. This screening process is done as part of the research process.
Further Evaluation: After the initial telephone screening, potential subjects will meet with
the principal investigator, Dr. Eda Gorbis, who will ask the subject to sign an informed
consent form (ICF). The research procedures and treatment will be described in detail to the
subject and any questions will be answered by the principal investigator. The ICF will be
signed by the subject and the principal investigator, agreeing to those procedures in the
study that are considered research, acknowledging that their participation is voluntary, and
that they have been informed of the risks and benefits of the study. Research procedures
include cognitive testing, standardized rating scales, and clinical assessment
questionnaires discussed below.
When the ICF is signed, the potential subjects will meet with the study physician, Dr.
Kagan, for a comprehensive psychiatric evaluation and physical assessment to confirm a
primary diagnosis of BDD according to the criteria of the Diagnostic and Statistical Manual
of Mental Disorders - Fourth Edition (DSM-IV), and identify any confounding comorbidity,
physical health, or medication issues which may or may not preclude their participation in
treatment. According to subjects' self-report, those who are currently on medication for
their BDD must have a regular prescribing physician who can continue prescribing their
medication.
Upon confirmation of inclusion into the study, subjects will then be given appointments for
cognitive testing and further clinical assessments by the study independent evaluator. The
Mini International Neuropsychiatric Interview for DSM-IV (M.I.N.I.; Sheehan & Lecrubier et
al., 1998) will be used to determine comorbid disorders that are excluded from the study,
which will take approximately 45 minutes to complete. The Wechsler Adult Intelligence Scale
- Third Edition (WAIS-III; Wechsler 1997), which is an instrument that assesses verbal and
nonverbal intellectual functioning, will be used to determine subjects' cognitive capacity,
and will take approximately 90-120 minutes to complete.
Assessment Instruments: One week prior to treatment, subjects will be administered a battery
of clinical rating scales and questionnaires to determine the severity of their BDD and any
secondary symptoms. This same assessment battery will be given immediately following
treatment to determine the level of efficacy of each of the two treatment groups. These
scales include the Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Body
Dysmorphic Disorder Examination-Self Report (BDDE-SR), BDD Diagnostic Module (BDDDM), Y-BOCS
Symptom Checklist, Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Hamilton Rating Scale for
Depression (Ham-D), Hamilton Anxiety Rating Scale (HARS), Fixity of Beliefs Questionnaire,
Global Assessment of Functioning (GAF), NIMH Global Obsessive-compulsive Scale, Brown
Assessment of Beliefs Scale (BABS), Obsessive-Compulsive Inventory (OCI),
Obsessive-Compulsive Rating Scale (OCON), Fear Survey Schedule (FSS), and the Revised
Willoughby Questionnaire. These will take approximately 90-120 minutes to complete.
Randomization: Following assessment, subjects will be pseudo-randomized into either the
mirror retraining treatment group or the crooked mirror treatment group.
Pseudo-randomization means that subjects will first be assigned to one of the two groups
randomly, then group membership will be remixed if needed to assure that there is no
significant between-group difference in pretreatment BDD-YBOCS scores. If possible, groups
will also be matched for age and gender.
Intensive Cognitive-Behavioral Therapy: After subjects complete the pre-treatment
assessments, the study therapist will meet with participants to design their treatment
program. Treatment will be conducted every day for 15 days, Monday through Friday, for
90-minute sessions. In addition, as a part of therapy, subjects will complete homework
assignments daily. Intensive CBT for BDD is done in the form of Exposure and Response
Prevention (ERP) with either the mirror retraining method or the crooked mirror
externalization therapy. This involves prolonged and repeated exposures to images of the
perceived defects, and prevention of ritualistic behavior (e.g., camouflaging with
cosmetics, skin-picking, etc.).
Inclusion Criteria:
- Age 18-60
- Meets DSM-IV criteria for BDD
- Baseline 12-item BDD-YBOCS score >15
- Baseline 33-item BDDE score > 99
- Baseline 3-item BDDDM score > 9
- IQ > 90
- English-speaking
- No changes in psychotropic medication during or 12 weeks prior to study
Exclusion Criteria:
- No medical contraindications
- No co-morbid psychiatric contraindications (psychosis, bipolar disorder, Tourette's
or other tic disorder, panic disorder, PTSD, ADHD, anorexia nervosa, bulimia)
- Current suicidality
- Primary diagnosis of OCD, depression, or substance abuse
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