CBT is a promising approach for treating BDD. Early case reports indicated a successful outcome with exposure therapy (Marks and Mishan 1988; Schmidt and Harrington 1995), audiovisual self-confrontation (Klages and Hartwich 1982), systematic desen-sitization (Munjack 1978), and cognitive plus behavioral techniques (Cromarty and Marks 1995; Gomez-Perez et al. 1994; Newell and Schrubb 1994). Studies using exposure (e.g., exposing the perceived defect in social situations and preventing avoidance behaviors), response prevention (e.g., helping the patient avoid compulsive behaviors, such as mirror checking), and cognitive restructuring have found these approaches to be effective for a majority of patients. In a report of 5 patients, 4 improved using these techniques in 90-minute sessions 1 or 5 days per week (with the total number of sessions ranging from 12 to 48) (Neziroglu and Yaryura-Tobias 1993). Techniques included covering or removing mirrors, limiting grooming time, stopping use of makeup, and having patients sit in crowded waiting rooms. In an open series of 13 patients treated with group CBT, BDD significantly improved in twelve 90-minute group sessions (Wilhelm et al. 1999). In a study of 10 patients who participated in an intensive behavioral therapy program, including a 6-month maintenance program, improvement was maintained for up to 2 years (McKay 1999).
Two studies used a waiting-list control design. In a study of eight weekly 2-hour sessions of group CBT, cognitive techniques plus exposure and response prevention were effective for 27 (77%) of 35 women, with patients in the CBT group improving more than those in the no-treatment waiting-list control group (Rosen et al. 1995). However, patients appeared to have relatively mild BDD, and many seemed to be in a "diagnostic gray zone" between BDD and eating disorders. In a pilot study of 19 patients, there was significantly greater improvement among patients who participated in group CBT than among patients in a no-treatment waiting-list control group, with the symptoms of 7 (77%) of 9 patients no longer meeting criteria for BDD (Veale et al. 1996b). It is unclear whether exposure and response prevention alone are effective for treating BDD. Some studies suggest that it is effective (McKay et al. 1997), whereas others indicate that it is not and suggest that cognitive restructuring is a necessary component of treatment (Campisi 1995), perhaps because of the poor insight and depression characteristic of BDD.
Data on CBT, although promising, are from clinical series and studies using a waiting-list control design, which does not control for therapist attention and other nonspecific treatment factors. Psychotherapy studies using an attention control group or an alternative treatment are needed. Also requiring empirical investigation are questions about whether a cognitive component is necessary; whether CBT alone is effective for patients who are severely depressed, suicidal, and delusional; and whether booster sessions are needed. Further study is needed to determine the minimum number of required sessions and session frequency. In published studies, the number of treatment sessions varied from twelve 90-minute sessions (Wilhelm et al. 1999) to forty-eight 90-minute sessions (Neziroglu and Yaryura-Tobias 1993), whereas in clinical settings, far fewer sessions may be available because of insurance limitations.
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