When The Mirror Is Wrong: A Multi-Method Efficacy Study Of An Acceptance And Compassion-Based Group Intervention For Body Dysmorphia

Body dysmorphic disorder (BDD) is a mental disorder described by an excessive preoccupation or obsession with a perceived defect or imperfection in one's physical appearance or body functionality that is either imperceptible or barely noticeable by others, as defined in the DSM-5. While general appearance concerns are normal, in BDD these concerns are taken to the extreme and have a great impact on the individual's daily functioning and quality of life. To match diagnostic criteria, individuals must also engage in repetitive activities/compulsions (e.g., mirror checking, skin plucking, and excessive grooming). BDD is also known to be associated with poor cognitive flexibility, impulsivity, and affective processing, showing specific neural correlates. BDD is a serious mental condition that can cause a great deal of distress. However, BDD has been globally overlooked and in Portugal, before the current project, screening or assessment measures had not yet been validated, and no specialised treatment options are currently available. BDD has long been underdiagnosed, since it usually involves a lack of insight, delusional beliefs, and is highly associated with shame and severe body-image problems, leading to symptom concealment.

In the last decades, pharmacological (Serotonin reuptake inhibitors) and Cognitive Behavioural Therapy (CBT) interventions have been successfully developed for the treatment of BDD, but with some limitations, specifically regarding relapse rates. More recently, 3rd generation interventions, such as Acceptance and Compassion-based therapy, have shown promising results in BDD-related disorders (e.g., obsessive-compulsive and eating disorders) as well as with non-clinical samples (e.g., body dissatisfaction).

Despite its promising results, the application of 3rd generation interventions in BDD is still limited. So far, only pilot studies have tested such interventions in adults with BDD symptomatology. In addition, several authors have recommended integrating compassion in the treatment of BDD, working to increase and specifically target shame and self-criticism, but no studies test the efficacy of compassion skills/strategies for BDD. Our hypothesis is that by targeting specific processes involved in the development of BDD, not only will symptoms improve, but overall quality of life and relapse rates will be positively impacted. This project aims to foster the assessment and treatment of BDD while contributing to the progress of 3rd generation interventions.

Thus, we will adapt, implement, and investigate the feasibility and preliminary efficacy of the online version of the Mind-over-Mirror, an innovative programme, which combines ACT and compassion-strategies, to be delivered in group format to individuals presenting BDD symptomatology. The programme's feasibility and preliminary efficacy will be evaluated within a parallel arm study comparing against a control condition/waiting list (individuals with BDD symptomatology who will not receive any type of psychological intervention during the course of the trial). A longitudinal and multi-methods outcomes approach will be implemented (primary outcome: BDD symptomatology; secondary outcomes: general mental health [depression] and ACT, and compassion-related psychological processes [self-compassion, body-specific and general psychological flexibility, and self-criticism]; other non-mandatory and exploratory outcomes: cognitive functioning [Emotional Stroop Task and Emotion Recognition Task] and associated brain activity changes using functional Near-Infrared Spectroscopy (fNIRS). All participants will be assessed at three moments (baseline, post-intervention and 3-month follow-up), as well as report weekly BDD symptomatology.

All procedures inherent to this project were approved by the Ethics Committee of the Faculty of Psychology and Educational Sciences, University of Coimbra. Informed consent from each participant was required prior to any data collection. The voluntary, confidential and pseudo-anonymised nature of the project was clearly explained, as well as the option to decline or withdraw at any moment without any negative consequence.