An Empirical Model of Body Image Disturbance Using Behavioral Principles Found in Functional Analytic Psychotherapy and Acceptance and Commitment Therapy

Article excerpt

The concept of body image disturbance encompasses a variety of psychological factors including general body dissatisfaction, distressing emotions over one's body image, overinvestment in one's appearance, and poorer quality of life (Cash & Grasso, 2005; Cash, Phillips, Santos, & Hrabosky, 2004). Cash and colleagues (2004) propose that body image disturbance lies on a continuum where less severe negative body image can be considered body image dissatisfaction, while the extreme end of the continuum contains greater distress consistent with Body Dysmorphic Disorder (BDD). BDD is characterized by an excessive preoccupation with an imagined or slight physical defect leading to significant distress or impairment in functioning (American Psychiatric Association, 2000). According to the current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; APA, 2000), BDD is present if these criteria are met and cannot be attributed to an eating or other psychological disorder. Aside from preoccupation and impairment in functioning, typical characteristics demonstrated by individuals suffering from BDD include concern about several body parts, high frequency of suicidal thoughts and attempts, and comorbidity with other disorders (Phillips, Menard, Fay, & Weisberg, 2005).

Prevalence rates for BDD have been examined for different populations and range from 0.7 to 1.1% in community samples (Faravelli et al., 1997; Otto, Wilhelm, Cohen, & Harlow, 2001; Phillips et al., 2005). College student samples have slightly higher rates (ranging from 4.8 -13%; Biby, 1998; Bohne et al., 2002; Cansever, Uzun, Donmez, & Ozsahin, 2003), and Phillips et al. (2005) found similarly elevated rates (13%) among psychiatric inpatients. The prevalence of BDD is likely higher but may be underreported for a variety of reasons including individual shame and hesitancy to seek treatment (Fuchs, 2002), seeking cosmetic procedures in an attempt to fix the perceived defects (Cansever et al., 2003), and misdiagnosis of other disorders (Zimmerman & Mattia, 1998; see Pavan et al., 2008, for a review). Because it is relatively common in the general population, researchers continue to investigate possible causal variables to further understand and treat both body image disturbance and BDD.


The current DSM-IV-TR categorizes BDD as a somatoform disorder (APA, 2000; see Phillips et al., 2010, for a review of the history of BDD classification). Due to shared topographical characteristics (i.e., symptoms), there have been efforts to reclassify BDD with other disorders including mood and anxiety disorders (Toh, Russell, & Castle, 2009), as part of the Obsessive-Compulsive Disorders spectrum (McKay, Neziroglu, & Yaryura-Tobias, 1997; Phillips et al., 2010), and as an eating disorder (Grant & Phillips, 2004; Rosen & Ramirez, 1998). Additionally, the DSMIV-TR inclusion of Delusional Disorder, Somatic Type, as a psychotic variant of BDD has prompted research on comparisons of delusional versus nondelusional types of the disorder (Phillips, 2004; Phillips, Menard, Pagano, Fay, & Stout, 2006; Phillips et al., 2010).

Thus, multiple arguments have been posed in the literature about how best to categorize or frame BDD. While there are merits to re-categorizing BDD, it is unclear this effort will serve to clarify its etiology or suggest appropriate intervention strategies. What results, then, is a nosological endeavor in typology without clinical application. It may be more useful to focus on psychological variables related to etiology and maintenance of body image disturbance. This paper describes a behavior analytic model of body image disturbance. An empirical test of the model is also reported. Inasmuch as BDD represents the more extreme end of the continuum of suffering, this same core conceptualization could be applied to less severe struggles with body image disturbance. …