Introduction
BDD, third-wave, depressive, psychiatric, BDD behaviors, Shame, binge eating disorder, depression, dysmorphic disorder
DISORDER
Shame is considered central in body dysmorphic disorder (BDD) and empirical
accounts highlight the link between shame and BDD symptoms as well as common
negative psychosocial effects of the disorder, yet there is a lack of
interventions addressing shame in this context. In the past decade, Acceptance
and commitment therapy (ACT) and interventions that foster self-compassion have
shown promise for reducing the negative effects of shame in a range of clinical
problems. The aim of the present study was to develop and evaluate an acceptance
and compassion-based treatment specifically targeting shame in BDD. Using a
randomized nonconcurrent multiple baseline design, the 12-session intervention,
ACT with Compassion (ACTwC), was examined in a psychiatric outpatient sample of
five adults diagnosed with BDD. The daily ratings showed marked reductions in
BDD-behaviors and self-criticism at posttreatment for four of five participants,
while three participants demonstrated decreases in body shame compared to
baseline. Improvements were maintained at 6-months follow-up. The intervention
also led to reliable long-term improvements in general shame, overall
BDD-symptoms, depressive symptoms, and quality of life for four of five
participants. All treatment responders showed significant gains in psychological
flexibility and self-compassion. Participants reported high credibility and
satisfaction with the treatment. These preliminary results suggest that ACTwC
may be a promising approach to treating shame in BDD, worthy of further
investigation.Body dysmorphic disorder (BDD), characterized by a preoccupation with a perceived
flaw in appearance (One way to improve treatment outcomes for BDD may be to target shame, an emotion
considered central in this disorder (Shame refers to the affective experience of perceiving the self as intrinsically
flawed and socially undesirable (Accumulating research points to considerable negative effects of shame in BDD. Shame
contributes significantly to increased overall BDD-symptoms and commonly
co-occurring negative psychosocial consequences, such as limited functioning,
hopelessness, depression, and suicidal thoughts (Even though research shows a link between shame and severe adverse outcomes in BDD,
there are yet no evaluations of interventions specifically targeting shame in this
disorder. One reason for this is perhaps that CBT, the most established
psychological treatment method for BDD, is focused on treating maladaptive
cognitions and diagnosis-specific symptoms, rather than shame. However, when
treating people who are highly shame-prone and self-critical, theorists suggests
that shame needs to be directly targeted in treatment (In the past decade, evidence has emerged supporting the use of interventions
developed in more recent “third-wave therapies” building on the CBT tradition, for
conditions where shame is a prominent feature. Treatment approaches such as
Acceptance and commitment therapy (ACT) and Compassion focused therapy (CFT), have
shown potential to reduce shame and associated problems in a range of clinical
conditions; for example, binge eating disorder (ACT is proposed to be an effective approach for reducing negative effects of shame
due to the treatment’s potential to decrease experiential avoidance and increase
psychological flexibility, including weakening the influence of self-critical
thoughts (Another promising approach for alleviating detrimental effects of shame and
self-criticism is to build self-compassion (Based on advances in the research field on shame and previous research on BDD, we
have developed a psychological treatment intervention targeting shame in BDD. The
manualized treatment, ACT with Compassion (ACTwC) for BDD, integrates ACT with
elements from CFT and knowledge on BDD. ACTwC for BDD, is designed to target shame
and self-criticism and increase psychological flexibility and self-compassion with
the overarching goal of increasing quality of life in patients suffering from BDD.
An earlier version of this treatment that did not include elements focused on
compassion and shame (ACT for BDD) was tested in a group therapy format with 21
patients with BDD (The purpose of the present study was to evaluate the effect and feasibility of a
psychological treatment intervention directly targeting shame in BDD. In this early
stage of evaluating a new treatment approach to BDD, our objectives were to
investigate; (a) preliminary effectiveness and (b) patient’s acceptance of and
satisfaction with the treatment. Using a multiple baseline design, the treatment’s
effect on the primary outcomes of body shame, self-criticism, and BDD behaviors, was
evaluated. Secondary outcomes were overall symptoms of BDD, depression, quality of
life, self-compassion, and psychological flexibility. Treatment feasibility was
evaluated by investigating patient’s perceived credibility and expectancy as well as
satisfaction with the intervention. We aimed to evaluate the feasibility of the
treatment in a real-world context and therefore chose to conduct the study in a
psychiatric outpatient clinic.