The University of Maine DigitalCommons@UMaine Electronic Theses and Dissertations Fogler Library 5-2002 A Single Subject Investigation of Behavioral and Cognitive Therapies for Body Dysmorphic Disorder April O'Grady Follow this and additional works at: http://digitalcommons.library.umaine.edu/etd Part of the Cognitive Psychology Commons Recommended Citation O'Grady, April, "A Single Subject Investigation of Behavioral and Cognitive Therapies for Body Dysmorphic Disorder" (2002). Electronic Theses and Dissertations. 61. http://digitalcommons.library.umaine.edu/etd/61 This Open-Access Dissertation is brought to you for free and open access by DigitalCommons@UMaine. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of DigitalCommons@UMaine. A SINGLE SUBJECT INVESTIGATION OF BEHAVIORAL AND COGNITIVE THERAPIES FOR BODY DYSMORPHIC DISORDER BY April O'Grady B.Sc. Memorial University of Newfoundland, 1993 A THESIS Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy (in Psychology) The Graduate School The University of Maine May, 2002 Advisory Committee: Jeffrey Hecker, Associate Professor of Psychology, Co-Chair Geoffrey Thorpe, Professor of Psychology, Co-Chair Bruce Hale, Cooperating Associate Professor of Psychology Alan Rosenwasser, Professor of Psychology Sandra Sigmon, Associate Professor of Psychology Alan Stubbs, Professor of Psychology A SINGLE-SUBJECT INVESTIGATION OF BEHAVIORAL AND COGNITIVE THERAPIES FOR BODY DYSMORPHIC DISORDER By April O'Grady Thesis Co-Advisors: Dr. Jeffrey Hecker, Dr. Geoffrey Thorpe An Abstract of the Thesis Presented In Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy (in Psychology) May 2002 Body dysmorphic disorder (BDD), a psychological disorder characterized by an intense preoccupation with an imagined physical defect, causes extreme distress and leads to depression, divorce, and suicide. Currently, empirically- supported treatments include cognitive-behavioral therapy (CBT) and selective serotonin-reuptake inhibitors, however, one important component of treatment literature yet to be investigated is the relative efficacy of cognitive or behavior therapy as a sole treatment. In particular, examinations of change processes throughout the course of treatment are needed. Thus, the identification of necessary treatment components in the CBT package and the isolation of specific change processes could lead to a more streamlined and effective treatment approach. The current study utilized a multiple baseline, treatment crossover design to investigate change processes during either behavior therapy (BT) or cognitive therapy (CT) for BDD. Following a diagnostic assessment including a semi- structured interview for BDD, six individuals diagnosed with the disorder were invited to participate, five of whom completed the study. Participants received eight sessions of either BT or CT, followed by the same number of sessions of the remaining treatment. BT involved exposure with response prevention (ERP), and required the completion of ERP exercises both at home and in session. CT sessions followed Beck's (I967, 1976) approach, and involved the identification and challenging of cognitive distortions. In addition to a battery of self-report questionnaires administered at each phase change and at follow-up, daily recordings of compulsive behaviors, appearance-related self-statements, and global distress were gathered, as well as weekly third party assessments of behavior. Visual analysis of daily recordings demonstrated improvement for three of the five participants, with behavior therapy appearing to be most effective in reducing daily BDD symptoms. In addition, following completion of both cognitive and behavioral treatments, three of the five participants met criteria for clinically significant improvement on self-report measures of BDD symptoms and depression. Finally, investigation into the covariation of BDD-related thoughts and behaviors revealed results for two participants. Discussion focused on implications for behavioral and cognitive theories of symptom maintenance, as well as on interpreting current findings within the body of BDD outcome literature and further clinical implications. ACKNOWLEDGEMENTS I would like to thank my advisors, Dr. Jeffrey Hecker and Dr. Geoffrey Thorpe, for supporting me in this project and for reading, editing, and re-reading many drafts. 1 am especially grateful to Dr. Hecker for providing clinical supervision throughout the study and to Dr. Thorpe for providing therapy in the pilot project. Thank you, also, to the members of my committee Dr. Sandra Sigmon, Dr. Alan Stubbs, Dr. Bruce Hale, and Dr. Alan Rosenwasser for their helpful suggestions and valuable insight. I am very grateful to Kristin Maki and Annalyn Mercado for voluntarily being therapists in the study, and to the University of Manitoba Department of Clinical Health Psychology and Dr. John Walker for supporting the continuation of this study during my internship. Much gratitude is also owed to the clients who devoted considerable time and effort without a guarantee of success. Thank you to my family for their constant love, humor, and support (both emotional and financial!). I could not have done this without all of the enthusiastic encouragement you have given me over the years. Finally, thank you to my husband. Your love and support throughout this process was invaluable to my success. TABLE OF CONTENTS ACKNOWLEDGEMENTS .............................................................. ii LIST OF TABLES ........................................................................viii LIST OF FIGURES ...................................................................... X Chapter 1. INTRODUCTION................................................................ History and Demographics.................................................. Differential Diagnosis and Comorbidity ................................... Connections Between BDD and Obsessive-Compulsive Disorder ........................................................................ Behavioral Theory of OCD ................................................... Behavioral Theory of BDD................................................... Beck's Cognitive Theory ...................................................... Cognitive Theory of BDD ..................................................... Empirical Support for ERP and CT with OCD ........................... Additional Theories of BDD.................................................. Evolutionary significance ............................................. Selective attention ...................................................... Psychodynamic theory ................................................ Treatment of BDD............................................................... Methodological Issues......................................................... 43 Single-participant designs ............................................ 43 Response covariation .................................................. 51 Current Study .................................................................... 5 3 Hypotheses Related to Behavior Therapy ................................ 58 Hypothesis 1.............................................................. 58 Hypothesis 2 .......................................................... 58 Hypothesis 3 .............................................................. 58 Hypothesis 4 .............................................................. 59 Hypotheses Related to Cognitive Therapy ............................... 59 Hypothesis 5 .............................................................. 59 Hypothesis 6 .............................................................. 59 Hypothesis 7 .............................................................. 59 Hypothesis 8 .............................................................. 59 Hypothesis Related to Combined Cognitive and Behavior Therapies - Hypothesis 9 ...................................................59 2 . METHOD ............................................................................ 60 Participants..................................................................... 60 Therapists ..........................................................................60 Measures ..........................................................................-61 Total Compulsive Behavior Score (TCBS)........................ 61 Total Negative Self-statements Score (TNSS) .................. 61 Global Distress Rating (GDR) ........................................ 62 Third Party Measure ..................................................... 62 Body Dysmorphic Disorder Examination (BDDE)................ 62 The Yale-Brown Obsessive Compulsive Scale for Body Dysmorphic Disorder (YBOCS-BDD)..................... 63 The Appearance Schemas Inventory (ASI) ....................... 64 The Social Avoidance and Distress Scale (SADS) .............. 64 The Overvalued Ideas Scale (OVIS) ................................ 65 The Beck Depression Inventory-ll (BDI-II) .......................... 66 Design ..............................................................................66 Procedure ................. ... ............................................... 67 Assessment ................................................................ 67 Behavior therapy ......................................................... 69 Cognitive therapy ........................................................