Discussion
depressive, depression, psychiatric, self-criticism
SECONDARY, REMISSION
This study used a controlled multiple baseline design methodology to evaluate a
12-session acceptance and compassion-based intervention targeting shame in BDD. Our
first aim, to investigate preliminary effectiveness of ACTwC for BDD, was supported.
The intervention led to large improvements in BDD-behaviors and self-criticism for
all but one participant, and reductions in body shame for three of five
participants. The standardized outcome measures administered pre-, mid-, and
posttreatment followed the same pattern as the daily measures with significant
decreases for most participants in overall BDD-symptoms, self-criticism, and general
shame at posttreatment. In addition, treatment led to large and reliable
improvements in quality of life and depressive symptoms for all but one participant.
Improvements were maintained at 6-months follow-up.The intervention’s effect on shame and self-criticism is worth reflecting on in some
more detail. Overall, self-criticism decreased faster and more consistently than
shame across most subjects. Body shame fluctuated from day-to-day throughout
treatment and the standardized measures even showed some increases in general shame
at midpoint. However, at follow-up the level of body shame had decreased compared to
baseline for three participants and general shame had significantly improved for
four of the participants compared to pretreatment. The slow and uneven gains in
shame is consistent with previous findings by The temporary increases and slow gains in shame during treatment phase may be
interpreted as an effect of a treatment focus on eliciting contact with previously
avoided feelings of shame. The ability to acknowledge, accept, and regulate the
experience of shame was promoted throughout treatment. In an ACT approach, fostering
awareness and openness to undesirable thoughts and feelings (e.g., of shame), is key
to reduce negative effects of inner experiences. In fact, the real goal in ACT is to
promote psychological flexibility and value-guided action in the presence of painful
emotions, rather than reducing emotions themselves. However, when psychological
flexibility in response to difficult thoughts and feelings increases, usually the
emotions are also perceived as less burdensome and tend to decrease, which may
explain the long-term reductions in shame.Even though the treatment was designed to target shame, it also had a large effect on
patient’s BDD-behaviors, providing some preliminary support for the proposition by
Furthermore, the secondary outcomes showed large and reliable treatment effects on
BDD-symptoms for most participants. At posttreatment, four of the five participants
could be classified as treatment responders, reflecting clinically meaningful
reduction on the BDD-YBOCS according to the predefined criterion, and as achieving
symptom remission at follow up. The treatment response and symptom remission rates
gained in this study is excellent compared to what is typically found in clinical
trials of BDD. In comparison, a study by In addition, the four responders in the present study made large and reliable
improvements in quality of life and depressive symptoms. They went from
moderate-severe depression at pretreatment to mild or subclinical symptoms after
treatment, and from low quality of life to levels comparable to non-clinical samples
in previous studies (Congruent with expectations, the treatment also had a significant effect on the
proposed treatment processes. Most participants demonstrated increases in
psychological flexibility and self-compassion after treatment, suggesting that the
intervention strengthened these abilities. Additional research is needed to evaluate
the impact of these proposed treatment processes. Future studies should investigate
the mediating or moderating potential of these processes on the effects of shame in
BDD.The second objective of the present study was to evaluate the feasibility of this new
treatment approach to BDD. Most participants reported high levels of satisfaction
with the intervention and stated that it met almost all their needs. They all found
the treatment to be highly credible. Hence, the second aim was supported, indicating
that ACTwC was acceptable to people with BDD and elevated shame, and feasible to be
delivered in a psychiatric outpatient setting.Strengths of this study include the randomized multiple baseline design that
controlled for threats to internal validity, such as the passage of time and
repeated assessments. Further, the daily assessment method has the advantage that it
is sensitive to change and fluctuations in mood and behaviors. Additional strengths
were the real-world setting and the large improvements across patients with
considerable symptoms and low quality of life. Moreover, we used three different
therapists who after moderate training were able to deliver treatment adequately,
providing some initial evidence that the intervention can be successfully delivered
in a real-world context.Single-case experimental designs (e.g., multiple baseline) are suitable for initial
evaluation of psychological treatments (Another limitation of the study is the relatively unknown reliability and validity of
the daily assessments of body shame and self-criticism. The daily measures consisted
of single item questions that required participants to be able to understand these
constructs. Identifying and discriminating self-conscious emotions can be difficult
(