CBT for body dysmorphic disorder

1. Introduction

Version followed: modular CBT-BDD as set out in Wilhelm, Phillips & Steketee (2013), Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual (Guilford), delivered in about 22 individual sessions over 24 weeks as in the Wilhelm et al. (2014) RCT. The session map below comes from the manual's published table of contents. Procedures come from the IOCDF therapist's guide written by the manual's team (Hartmann, Greenberg & Wilhelm). The manual's own text and the RCT full text are not drawn on, so manual-specific details beyond these sources are marked [uncertain].

CBT-BDD is an individual, modular cognitive-behavioural treatment for body dysmorphic disorder (BDD), adapted from CBT for OCD. Every patient gets a core set of modules: assessment, psychoeducation, case formulation, motivational enhancement, cognitive restructuring, exposure with ritual prevention, perceptual (mirror) retraining, advanced cognitive work and relapse prevention. Optional modules are added when the formulation calls for them: skin picking or hair pulling, weight/shape/muscularity concerns, cosmetic-treatment seeking, and depression. [source: Guilford ToC; IOCDF guide; Beck Institute RCT summary]

How change happens: in this model, BDD persists because the person zooms in on small details of appearance and loses the whole picture. They overestimate how much others notice and judge. They treat a minor flaw as proof of a big personal defect, such as being unlovable. The resulting anxiety, shame and sadness are escaped through rituals (mirror checking, grooming, picking, camouflage, reassurance seeking, surgery seeking) and through avoidance. These bring short-term relief and so are reinforced. Treatment interrupts the cycle at each point: it retrains perception and attention, evaluates appraisals, drops rituals and avoidance through exposure, and broadens the basis of self-worth. [source: IOCDF guide]

2. Framework

Format. Individual, roughly weekly, about 22 sessions over 24 weeks in the 2014 RCT (36 adults; 12-week waitlist comparison). [source: Beck Institute RCT summary] The exact session length and how sessions were spaced across the 24 weeks were not confirmed. Weekly sessions of about an hour that taper later is a common reading, but it is [uncertain]. The manual is written for adults and adolescents and includes more than 50 reproducible handouts and forms. [source: Guilford ToC/description]

Session map (manual table of contents) [source: Guilford ToC]

Phase	Sessions	Content named in the manual	Goal
Groundwork (therapist preparation)	before S1	Special considerations; diagnosing and assessing BDD and associated symptoms; enhancing motivation	Confirm diagnosis, risk, comorbidity, insight and readiness
Introductory	S1	Assessing BDD, orienting the patient to CBT-BDD, assessing motivation	Engagement; shared view of the problem
Introductory	S2	Education and case formulation	Personal model of the BDD cycle; chooses optional modules
Introductory	S3	Setting goals, describing CBT-BDD, assessing thoughts	Goals; begin thought monitoring
Core	S4–5	Evaluating self-defeating thoughts	Label thinking errors; test thoughts for evidence and usefulness
Core	S6	Introducing exposure	Hierarchy; first exposure
Core	S7–9	Adding ritual prevention	Track, delay and cut rituals during and between exposures
Core	S10	Perceptual retraining for mirror checking	Neutral, whole-body mirror use
Core + optional	S11–20	Advanced cognitive strategies and moving forward	Core beliefs, self-worth, generalisation; optional modules woven in
Ending	final sessions	Termination, relapse prevention, booster sessions	Consolidate; self-therapy plan; boosters

Optional modules (Part IV of the manual): skin picking and hair pulling; weight, shape and muscularity; cosmetic treatment; depression. [source: Guilford ToC] When and for how long each optional module is inserted is not stated in the sources. Clinically, insert one once the core skills it builds on are in place, unless it is blocking engagement (for example, severe depression or a booked cosmetic procedure). [synthesis]

Criteria for moving on. The manual's explicit criteria are not drawn on [uncertain]. Sources and reasonable working criteria:

Formulation to cognitive work: the patient can map their own trigger → appraisal → emotion → ritual/avoidance cycle. [source: IOCDF guide (model guides modules); criterion is synthesis]
Cognitive work to exposure: the patient can catch and label appearance thoughts in self-monitoring. Cognitive work comes first because it is less anxiety-provoking. [source: IOCDF guide; app protocol]
Exposure to ritual prevention: introduce ritual prevention soon after exposure begins, not after exposure is mastered. [source: IOCDF guide]
Automatic thoughts to core beliefs: move on once automatic thoughts are reasonably manageable. [source: IOCDF guide]
Into termination: big reductions in rituals and avoidance, a return to valued activities, and the patient running their own exposures and thought records. Track progress with the clinician-rated BDD-YBOCS, the BABS for insight, and a depression measure with a suicide item. [source: app protocol (measures used by the same team); thresholds are synthesis]

Named variants (not followed here). A smartphone version from the same team (MGH, Wilhelm PI): about 12 weeks, eight components (education/assessment and model, self-monitoring, cognitive techniques, exposure, response prevention, mindfulness/perceptual retraining, valued activities, relapse prevention), motivational enhancement woven throughout, and a CBT-trained coach averaging under 15 minutes a week by message. [source: NCT03221738 protocol] The self-help book by Wilhelm (2006), Feeling Good About the Way You Look, underlies the app. [source: NCT03221738 protocol]

Where it sits in care (UK). NICE CG31: CBT including ERP for mild impairment, individually or in groups. For moderate impairment, offer a choice of an SSRI or more intensive individual CBT. For severe impairment, offer both. Children and young people get CBT with family/carer involvement. [source: NICE CG31 1.5.1.5–1.5.1.10]

3. Guiding principles

[source: IOCDF guide unless tagged otherwise]

Formulation drives the modules. Every patient gets the core modules; optional ones are chosen from their personal model. Practical: write the model down at S2 and refer back to it when adding a module. [source: Guilford ToC; IOCDF guide]
Validate the suffering; don't debate the appearance. Practical: aim the treatment at distress and lost life, not at whether the nose is really crooked.
Usefulness over truth when insight is poor. Practical: ask "Does this belief help you live the life you want?" instead of "Is it true?"
Motivational enhancement throughout. Practical: use MI not only at intake but whenever ambivalence returns, e.g. before a hard exposure or when surgery comes back up. [source: IOCDF guide; app protocol]
Ask directly; expect concealment. Practical: patients hide BDD out of shame, so ask about appearance worries, camouflage, picking and mirror behaviour outright. [source: IOCDF guide; NICE 1.4.2.2]
Collaborative, Socratic, nonjudgmental stance. Practical: guide with questions; the patient draws the conclusions.
Start exposure where success is likely. Practical: first exposure mild to moderate, then climb.
Bring in ritual prevention early. Practical: exposure with rituals left intact has little effect, so pair them within a session or two.
Clear rationale, warm push. Practical: explain why before each new technique, acknowledge the anxiety, and still ask for the step.
Treat exposures as experiments. Practical: write the prediction down before, and compare it with what happened after.
Whole picture, neutral words. Practical: replace zoomed-in, judgmental self-description with whole-body, descriptive language, both at the mirror and in daily attention.
Self-worth broader than appearance. Practical: deliberately build up non-appearance sources of worth (skills, relationships, values).
Return to valued life. Practical: as symptoms fall, schedule valued activities so gains are kept and lived. [source: app protocol]
Monitor risk continuously. Practical: assess suicidality and depression at intake and regularly throughout; suicide risk in BDD is high. [source: IOCDF guide; NICE 1.4.2.4, 1.5.4.9]
No collusion with appearance fixes; no judgment of them either. Practical: weigh cosmetic treatment pros and cons openly, and be clear that the model predicts it rarely relieves BDD. [source: IOCDF guide; NICE 1.4.2.3]
The patient becomes their own therapist. Practical: from mid-treatment, hand over planning of exposures and thought work. After treatment, the patient holds weekly self-therapy sessions. [source: IOCDF guide]
Do not reassure about appearance. Practical: reassurance from the therapist works as a ritual. Reflect the urge to seek it instead of answering it. [synthesis, derived from the IOCDF list of reassurance seeking as a ritual]

4. Intervention inventory

All example therapist language is illustrative wording written for this guide, not text from the manual. The manual's own worksheets and dialogues are not drawn on. Where a step below goes beyond what the sources describe, it is tagged [synthesis].

4.1 Screening and diagnostic assessment (pre-treatment and S1)

Purpose / when: Before treatment, and whenever a client presents with appearance distress, seeks cosmetic or dermatological treatment for minor flaws, or shows skin damage, camouflage, social withdrawal or depression. [source: IOCDF guide; NICE 1.4.2.1–1.4.2.2]
Steps:
1. Screen in your own words along NICE's five lines: worry about looks and wishing to think about it less; which features; hours a day preoccupied (more than about an hour a day counts as excessive); effect on life; effect on work and friendships. [source: NICE 1.4.2.2]
2. Ask directly about clues that are often concealed: mirror checking or mirror avoidance, camouflage (makeup, hats, clothing, posture), comparing, reassurance seeking, grooming and picking, cosmetic/dermatological/dental treatment history, ideas of reference (believing others stare or comment), being housebound, substance use. [source: IOCDF guide]
3. Use a structured interview for differential diagnosis: eating disorder (if the concern is only weight or shape and fits an eating disorder, treat that instead), OCD, depression, social anxiety. [source: IOCDF guide]
4. Rate severity with the clinician-rated BDD-YBOCS and insight with the BABS. Add a depression measure. Do not reproduce items; use the published instruments. [source: NCT03221738 protocol]
5. Note the insight level (good/fair, poor, absent/delusional); it determines how much motivational work you lead with. [source: IOCDF guide; DSM-5 insight specifier, general knowledge]
Example language (illustrative): "Many people who come in feel very worried about some part of how they look and find it hard to mention. Is that true for you at all?"
Watch for: minimising out of shame, and refusing to name the body part. Accept a vague answer at first and revisit it later. Check for muscle dysmorphia in clients who train or diet heavily.

4.2 Suicide and self-harm risk assessment and monitoring (throughout)

Purpose / when: At intake and regularly throughout; suicide risk in BDD is high, especially with depression. NICE says to assess self-harm and suicide risk in everyone diagnosed with BDD, and all children and young people before treatment. [source: NICE 1.4.2.4–1.4.2.5, 1.5.4.9; IOCDF guide]
Steps:
1. Do a full standard risk assessment at intake (ideation, intent, plans, history, protective factors). Include BDD-specific stressors: a refused or failed cosmetic procedure, appearance-related rejection, DIY procedures.
2. Repeat a brief check every session, or use the suicide item of a weekly self-report measure. In the app trial, any positive response prompted a clinician call within 24 hours. [source: NCT03221738 protocol]
3. Write a collaborative safety plan. Include lethal-means counselling: safe storage or removal, and limiting stockpiles of medication. NICE advises prescribing limited quantities for high-risk patients. [source: NICE 1.5.3.4; safety-plan step is standard practice / synthesis]
4. Recheck risk at predictable high-risk points: starting exposure or mirror work, setbacks, bad news about surgery, termination. [synthesis]
5. If risk rises, step up care (more frequent sessions, medication review, crisis services, multidisciplinary review). [source: NICE 1.5.4.9; synthesis]
Example language (illustrative): "When the distress about your skin is at its worst, do thoughts of not wanting to be alive come up?"
Watch for: hopelessness tied to the belief that "nothing can fix it", recent cosmetic disappointment, and worsening depression. Do not soften the questions for fear of offending.

4.3 Orientation to CBT-BDD (S1)

Purpose / when: S1. Sets out the collaborative, active nature of CBT-BDD, its homework, and its focus on preoccupation, rituals and avoidance. [source: Guilford ToC]
Steps: (1) Describe the structure: agenda, homework review, new skill, homework planning [general CBT structure; manual's exact session format uncertain]. (2) Explain that treatment targets preoccupation, distress, rituals and avoidance, not changing appearance. (3) Agree a rough number of sessions (about 22) and the measures you will repeat. (4) Agree how the client will contact you in a crisis.
Example language (illustrative): "We won't be working to change how you look. We'll be working on how much time and pain this takes from you, and on getting back the things it has pushed out of your life."
Watch for: the client hearing "you're imagining it". Pre-empt this by saying you take the distress as real.

4.4 Motivational enhancement (S1 and throughout)

Purpose / when: For reluctant clients, poor or absent insight, clients who see the problem as purely physical, and any point where ambivalence returns. The manual has a full chapter on it. [source: Guilford ToC ch. 5; IOCDF guide]
Steps:
1. Open by validating the distress and how much time BDD consumes, without debating the flaw. [source: IOCDF guide]
2. Frame the aim of treatment as reducing suffering and restoring function. [source: IOCDF guide]
3. Ask Socratic, nonjudgmental questions about the possible benefits of trying CBT. [source: IOCDF guide]
4. Develop discrepancy: ask what the client wants their life to look like in about ten years, then compare it with where BDD is taking it. [source: IOCDF guide]
5. With poor insight, switch from accuracy to usefulness: does the belief, or the ritual, help or cost? [source: IOCDF guide]
6. Use a costs/benefits list of keeping BDD habits versus changing them, and roll with resistance [standard MI; synthesis as to manual form].
Example language (illustrative): "You don't have to agree that your nose looks fine for us to work together. Can we look at what the checking and hiding have cost you this year?"
Watch for: change talk (the client naming costs, wishes, small intentions). It is working when the client agrees to a concrete goal, even while keeping the belief.

4.5 Psychoeducation (S2)

Purpose / when: S2 and as needed. Normalises the condition and introduces the model. [source: Guilford ToC; IOCDF guide]
Steps: (1) Explain BDD's prevalence and common features. (2) Distinguish body image (how you perceive and feel about your body) from appearance (how you look), and say the treatment targets body image. (3) Introduce contributing factors: biological, psychological and sociocultural. (4) Explain short-term relief versus long-term maintenance by rituals and avoidance. [source: IOCDF guide]
Example language (illustrative): "Body image is the picture in your head and the feelings attached to it. It can be painful even when other people see you very differently."
Watch for: the client recognising themselves ("that's exactly what I do"). Shame often drops once they realise others have the condition.

4.6 Personal CBT model / case formulation (S2)

Purpose / when: S2. Builds the shared map that guides which modules are used. [source: Guilford ToC; IOCDF guide]
Steps:
1. Take a recent, specific episode (e.g. getting ready for work).
2. Write down the trigger (mirror, photo, a comment, bright light).
3. Write down the selective attention (zooming in on a detail), the interpretation ("everyone will notice", "I'm repulsive", "I'll be rejected") and the meaning ("unlovable", "inadequate").
4. Write down the emotions: anxiety, shame, sadness, disgust.
5. Write down the coping: rituals (checking, camouflage, comparing, reassurance, grooming/picking, surgery seeking) and avoidance (social, work, intimacy, photos, mirrors).
6. Draw the arrows back: relief → reinforcement → stronger belief and more attention to the feature.
7. Flag symptoms that point to optional modules: picking or pulling, weight/shape/muscularity, cosmetic seeking, depression. [source: IOCDF guide (model components); diagrammatic steps are synthesis]
Example language (illustrative): "So the bathroom light catches your skin, your eyes go straight to the pores, and the thought is 'everyone will see'. What did you do next, and what happened to the anxiety?"
Watch for: a model that is all about the "flaw" and leaves out the attention and appraisal steps. Keep asking "what went through your mind?"

4.7 Goal setting (S3)

Purpose / when: S3. Turns the client's values into concrete, behavioural treatment targets. [source: Guilford ToC; app protocol (valued activities)]
Steps: (1) List the areas BDD has shrunk: work, study, friendships, dating, family, hobbies. (2) Write specific, observable goals, e.g. eat in the cafeteria, go out without the cap, cut getting-ready time. (3) Do not set appearance-change goals. (4) Rate how important and how confident the client is about each goal. [goal-format steps are synthesis]
Example language (illustrative): "If BDD took up less of your day, what would you be doing with the time you got back?"
Watch for: goals phrased as "look better" or "feel no anxiety". Turn them into actions.

4.8 Self-monitoring (S3 onward)

Purpose / when: From S3. Records triggers, appearance thoughts, emotions, and rituals or avoidance between sessions. [source: IOCDF guide; app protocol]
Steps: (1) Give a simple log with columns for situation, thought, emotion (0–100), ritual or avoidance, and time spent. (2) Log close to the event. (3) Review it at the start of each session. (4) Later, add a count of specific rituals (e.g. mirror checks per day) as a baseline for ritual prevention. [source: IOCDF guide (tracking rituals); format is synthesis]
Example language (illustrative): "Just catch the thoughts this week. You don't need to change anything yet."
Watch for: monitoring that turns into rumination or a new checking ritual. Keep entries brief and time-limited.

4.9 Identifying cognitive errors (S3–5)

Purpose / when: S3–5. Teaches the client to recognise distorted appearance thinking. [source: Guilford ToC; IOCDF guide]
Steps: (1) Introduce common errors with BDD examples: all-or-nothing thinking, mind reading, personalisation, plus others as relevant (e.g. magnification, emotional reasoning). (2) Have the client label errors in their own monitoring entries, in session and then as homework. [source: IOCDF guide names the first three; others are synthesis]
Example language (illustrative): "'They looked at me because of my hair': which thinking trap might that be?"
Watch for: the client using the labels to attack themselves ("I'm so irrational"). Keep the tone curious.

4.10 Evaluating self-defeating thoughts (S4–5, then ongoing)

Purpose / when: S4–5. Examines appearance thoughts for accuracy and usefulness. [source: Guilford ToC; IOCDF guide]
Steps:
1. Pick a hot thought from monitoring and rate belief (0–100).
2. Evidence: do others actually notice? What did people really do? What else could explain their behaviour?
3. Usefulness: does believing this help you? What does it stop you doing? Lead with this when insight is poor. [source: IOCDF guide]
4. Write a balanced alternative thought and re-rate belief and emotion. [standard CBT; synthesis]
5. Practise in written form daily as homework.
Example language (illustrative): "Suppose some people did notice the scar for a moment. What do you think they'd conclude about you as a person?"
Watch for: the client seeking certainty ("but how do I know they didn't notice?"). That is a cue to move to tolerating uncertainty through exposure, not to pile up more evidence.

4.11 Exposure with hierarchy (S6 onward)

Purpose / when: From S6. Reduces avoidance, builds tolerance of distress, and gathers information that disconfirms beliefs. [source: Guilford ToC; IOCDF guide]
Safety and consent: Get informed consent after a clear rationale: exposure is voluntary, graded and planned jointly, and the client can pause. Before starting, check current suicide risk, active substance misuse, and severe depression that would block engagement. If risk is acute, stabilise first (see 4.2). Exposures must never involve self-harm, DIY procedures or physically unsafe situations. For clients with medical injury from picking, coordinate with medical care. [source: IOCDF guide (rationale, start moderately); safety/contraindication steps are synthesis]
Steps:
1. Review the model to list the client's specific avoidance and rituals. [source: IOCDF guide]
2. Build a hierarchy together and rate each item 0–100. Examples: changing rooms, beach or pool, intimacy, being at work or school without camouflage, accepting social invitations, being photographed, bright lighting, sitting face-to-face. Include items that widen the client's social life. [source: IOCDF guide (examples); ratings are standard practice]
3. Choose a first item that is mildly to moderately difficult with a high chance of success. [source: IOCDF guide]
4. Before each exposure, record the feared prediction and its likelihood (see 4.12).
5. Carry it out, in session where possible (e.g. walk to a busy café with less makeup) and then as homework, repeated until distress and belief fall. Plan the length so the client stays until they have learned something, not just until they feel relief [synthesis].
6. Combine with ritual prevention: no checking, camouflaging or reassurance during or after the exposure. [source: IOCDF guide]
7. Debrief: what happened, what was learned, re-rate the belief, plan the next step.
Example language (illustrative): "This will feel uncomfortable, and that's part of how it works. Your brain needs to learn this for itself, not hear it from me. Which item feels hard but doable this week?"
Watch for: safety behaviours that undermine exposure (sunglasses, angling the face, staying near the exit, subtle camouflage). It is working when the client approaches situations they used to avoid, predictions fail, and distress falls across repetitions.

4.12 Behavioural experiments (with exposure, S6 onward)

Purpose / when: Every exposure is set up as a test of a specific negative prediction. [source: IOCDF guide]
Steps: (1) State a testable prediction, e.g. "If I go without my hat, someone will laugh at my thinning hair" (the IOCDF example, paraphrased). (2) Rate its likelihood. (3) Decide what would count as confirming evidence, defined in observable terms. (4) Run the experiment without rituals. (5) Compare outcome with prediction and write down the learning. [source: IOCDF guide; steps 3 and 5 are standard CBT]
Example language (illustrative): "What exactly do you expect to happen, and how would we know if it did?"
Watch for: reinterpreting outcomes ("they were just being polite"). Name it as mind reading and design a sharper test.

4.13 Ritual (response) prevention (S7–9 onward)

Purpose / when: Introduced right after exposure begins. Removes the behaviours that keep the beliefs going. [source: Guilford ToC; IOCDF guide]
Common rituals to target: mirror checking (or checking in other reflective surfaces), comparing or measuring features, camouflage with makeup, hair, clothing or posture, reassurance seeking, excessive grooming, skin picking, tanning, and seeking cosmetic or dermatological treatment. [source: IOCDF guide]
Steps:
1. Track each ritual: when, where, how often, how long. [source: IOCDF guide]
2. Pick one ritual and set a concrete reduction plan. Delay it (wait a set time before checking) or reduce it (fewer checks, a set time limit, less makeup in public). [source: IOCDF guide]
3. Use the reductions within exposures, e.g. go to a meeting without re-checking in the car mirror.
4. Step down further until the ritual is at a normal level or gone. Where the behaviour has a normal everyday form (grooming, makeup), agree a non-ritual standard, e.g. a fixed routine and time [synthesis].
5. Engage family or partners: have them stop answering reassurance questions, using an agreed kind reply [synthesis; NICE recommends family involvement for young people].
Example language (illustrative): "When the urge to check comes, try waiting ten minutes and notice what happens to the urge. You don't have to win the whole fight today."
Watch for: ritual substitution (from mirror to phone camera, from asking to scanning faces), and mental rituals such as covert comparing. It is working when time spent falls on the log, urges weaken, and the client reports more free time.

4.14 Perceptual (mirror) retraining (S10, then practised daily)

Purpose / when: S10, for clients who check mirrors close up, focus on disliked areas and use harsh self-talk, and also for those who avoid mirrors. Retrains how the client looks at themselves. [source: Guilford ToC ("Perceptual Retraining for Mirror Checking"); IOCDF guide]
Steps: [source: IOCDF guide]
1. Stand at conversational distance from the mirror, about two to three feet.
2. Describe the whole body from head to toe, at an even pace. Don't skip the liked or neutral areas, and don't linger on the disliked one.
3. Use neutral, specific, descriptive language instead of judgments. The IOCDF example contrasts a neutral "small bump on the bridge of my nose" with a judging "huge and crooked".
4. No rituals during the exercise: no zooming in, touching, picking, adjusting or extra lighting.
5. Practise in session with the therapist first. The therapist gently redirects judgmental words, then sets a time-limited daily practice (e.g. one session a day). Mirror use outside practice stays within the agreed limits. [practice schedule is synthesis; manual's specific timings uncertain]
Example language (illustrative): "Start at your hair and move down. Describe as if you were telling an artist what to paint: colour, shape, texture, no ratings."
Watch for: words that smuggle in judgment ("ugly", "too", "disgusting", "normal"), drifting back to the disliked area, and drifting closer to the mirror. It is working when the client can describe the disliked area in neutral words with less distress, and everyday mirror time falls. [A 2026 lab study used a similar guided, neutral whole-body mirror exposure; source: Schoenenberg & Martin, secondary]

4.15 Attention retraining and mindful observation (S10 onward)

Purpose / when: Carries perceptual retraining into daily life. Shifts attention away from one's own or others' appearance onto the environment and the task. [source: IOCDF guide; app protocol lists "mindfulness and perceptual retraining" together]
Steps: (1) Identify situations where attention locks onto appearance (meetings, conversations, public transport). (2) Practise deliberately directing attention outward: to what the other person is saying, the taste of food, the room, the task. (3) Notice appearance thoughts nonjudgmentally, without arguing or acting on them, and return attention to the task. (4) Rate the share of attention on appearance before and after. [source: IOCDF guide (steps 1–2); app protocol (nonjudgmental observation); steps 3–4 are synthesis]
Example language (illustrative): "At lunch tomorrow, see how much you can notice about the conversation: the jokes, the stories. When your attention slides to your jaw, just note it and come back."
Watch for: using "attention" to scan others' faces for reactions. That is a ritual. The aim is to be absorbed in the task, not to monitor.

4.16 Advanced cognitive strategies: core beliefs and the downward arrow (S11–20)

Purpose / when: Once automatic thoughts are manageable. Targets deeper beliefs such as being unlovable or inadequate, which filter experience and threaten lasting gains. [source: Guilford ToC; IOCDF guide]
Steps:
1. Take a hot appearance thought and use the downward arrow: "If that were true, what would it mean about you?" Repeat until a core belief emerges. [source: IOCDF guide]
2. Test the core belief with cognitive restructuring (evidence, alternative views) and with behavioural experiments that target it directly, e.g. reaching out socially and observing responses. [source: IOCDF guide]
3. Keep an ongoing log of experiences that fit a more balanced core belief [synthesis; standard CBT].
Example language (illustrative): "And if people did notice your skin and judged it, what would that say about you?" … "That I'm worthless." "Let's take that one seriously and look at it."
Watch for: the belief coming back with new evidence. Strong emotion when the core belief appears is expected; slow down and validate.

4.17 Self-esteem pie / broadening self-worth (S11–20)

Purpose / when: Reduces how much of the client's worth rests on appearance. [source: IOCDF guide]
Steps: (1) Draw a circle showing how much of self-worth appearance currently takes up. (2) List non-appearance sources: skills, achievements, moral values, relationships, roles. (3) Redraw the pie as the client would like it to be. (4) Plan actions that build the other slices. [source: IOCDF guide (steps 1–2); steps 3–4 are synthesis]
Example language (illustrative): "If appearance is three-quarters of the pie right now, what would you want filling the rest?"
Watch for: the client dismissing other qualities ("those don't count"). Treat that as a thought to examine.

4.18 Increasing valued activities (mid to late treatment)

Purpose / when: As symptoms fall, fills the time BDD took with valued, healthy activity. Supports maintenance and mood. [source: NCT03221738 protocol; IOCDF guide (return to valued activities)]
Steps: (1) Assess values by domain. (2) Choose activities linked to them. (3) Schedule them weekly and review them each session. (4) Overlap them with exposure items where possible. [synthesis based on protocol component]
Example language (illustrative): "You mentioned music used to matter. What's one small way to bring that back this week?"
Watch for: activities chosen only because they can be done hidden. Check for avoidance disguised as preference.

4.19 Relapse prevention and termination (final sessions)

Purpose / when: Final sessions. Consolidates skills and prepares for future challenges. [source: Guilford ToC; IOCDF guide; NCT03221738 protocol]
Steps:
1. Review which skills helped most, and write a personal summary of the model and the tools.
2. Predict high-risk times: life transitions such as college, job interviews, dating, stress and low mood. Plan specific responses. [source: IOCDF guide; app protocol]
3. Distinguish a lapse (a temporary slip) from a relapse (return to the old pattern). Prepare counters for self-critical thoughts after a slip. [source: NCT03221738 protocol]
4. Set up weekly self-therapy sessions: the client sets an agenda, reviews skills and sets a BDD-related goal for the week. [source: IOCDF guide]
5. Plan continued exposures for items left on the hierarchy.
Example language (illustrative): "If you notice yourself checking more after a stressful week, what's your first step?"
Watch for: fear of ending, and covert dependence on sessions for reassurance. Taper the spacing between sessions toward the end [synthesis].

4.20 Booster sessions (after termination)

Purpose / when: After the main course. Check progress, revisit skills and catch early lapses. [source: Guilford ToC; IOCDF guide]
Steps: Agree timing in advance (e.g. one or more over the following months; exact schedule in the manual [uncertain]). Re-administer the BDD-YBOCS. Review the self-therapy log. Troubleshoot. Restart targeted modules if symptoms are returning.
Example language (illustrative): "Let's look at what you've kept going and where BDD has tried to sneak back in."
Watch for: rises in ritual time or new camouflage. Act on them early.

Optional modules (manual Part IV)

The sources name these modules and their main strategy. Step-by-step content inside the manual's chapters 15–18 is not drawn on [uncertain], so the detailed steps below are built from the named strategy and are tagged [synthesis].

4.21 Skin picking and hair pulling module: habit reversal training

Purpose / when: When picking or pulling is driven by appearance ("fixing" blemishes or uneven hairs) or is part of the BDD cycle. [source: Guilford ToC ch. 15; IOCDF guide (habit reversal)]
Steps: [HRT components per standard habit reversal, Azrin & Nunn 1973; BDD adaptation is synthesis]
1. Awareness training: describe the behaviour in detail, plus early warning signs (hand to face, scanning skin by touch, mirror proximity) and high-risk situations.
2. Competing response: choose a physically incompatible, inconspicuous action (e.g. clench fists, hold an object) and keep it up for about a minute or until the urge passes.
3. Stimulus control: reduce cues, e.g. dim or cover magnifying mirrors, keep tweezers out of reach, wear gloves or plasters during high-risk times, limit bathroom time.
4. Link to the BDD formulation: challenge the appraisal behind picking ("I must get it smooth") with cognitive work, and pair with mirror retraining.
5. Social support: a chosen person gently prompts and praises use of the competing response.
6. Refer to medical care for infected or scarring skin.
Example language (illustrative): "Let's find the very first sign that a picking episode is starting. That's where the competing response goes."
Watch for: trance-like, automatic picking that monitoring misses. A sign it is working is fewer episodes and visible skin healing.

4.22 Weight, shape and muscularity module

Purpose / when: When the concern is weight, shape or muscularity, including muscle dysmorphia (the belief one is too small or insufficiently muscular), and an eating disorder has been ruled out as the better diagnosis. [source: Guilford ToC ch. 16; IOCDF guide; differential from IOCDF guide]
Steps: [synthesis built on the IOCDF statement that this module uses psychoeducation plus CBT tailored to shape/weight]
1. Psychoeducation on muscle dysmorphia and on how comparison and selective attention operate in gyms and on social media.
2. Add shape rituals to the ritual list: body checking (pinching, measuring, weighing, checking muscles in mirrors), comparing with others, excessive training, rigid diet rules, baggy-clothes camouflage.
3. Ritual prevention and exposure: e.g. skip a training session, wear fitted clothing, eat a meal without tracking it. Plan these jointly. No numeric weight, calorie or exercise targets are set in therapy.
4. Ask about anabolic steroid, supplement or other performance-enhancing substance use, and refer for medical review if present.
5. Cognitive work on rules linking size to worth.
Example language (illustrative): "What would it mean to you if you missed tomorrow's workout?"
Watch for: eating-disorder features emerging (restriction, compensatory behaviours). If they appear, reassess and coordinate with eating-disorder services.

4.23 Cosmetic treatment module

Purpose / when: When the client is seeking, planning or has had cosmetic, dermatological or dental procedures for the perceived flaw. [source: Guilford ToC ch. 17; IOCDF guide; NICE 1.4.2.3]
Steps:
1. Explore the client's beliefs about what the procedure will fix: appearance, but also acceptance, confidence, love. [source: IOCDF guide]
2. Weigh pros and cons nonjudgmentally, using motivational strategies. [source: IOCDF guide]
3. Review the client's own history: how did previous procedures affect preoccupation? Did the focus move to another feature? [synthesis]
4. Use cognitive strategies to test the belief that a changed appearance will solve the problem. [source: IOCDF guide]
5. Suggest putting procedures on hold for the course of treatment, and revisiting the decision afterwards [synthesis].
6. With consent, liaise with the cosmetic provider. NICE advises that people with BDD who seek such treatment be assessed by a mental health professional with BDD expertise. [source: NICE 1.4.2.3, 1.4.2.6]
Example language (illustrative): "If the surgery went perfectly, what do you imagine would be different in your life a year later?"
Watch for: DIY procedures and doctor-shopping (serious risks; check at every session), and despair after a refusal or poor outcome (re-assess suicide risk).

4.24 Depression module

Purpose / when: When comorbid depression is significant or interferes with engagement. [source: Guilford ToC ch. 18; IOCDF guide]
Steps: (1) Activity scheduling first: monitor activities and mood, then schedule rewarding and mastery activities in graded steps. (2) For more severe depression, add cognitive restructuring of depressive thoughts. (3) Keep monitoring suicide risk; consider medication review. [source: IOCDF guide (steps 1–2); NICE (step 3); scheduling detail is standard behavioural activation]
Example language (illustrative): "Let's plan two small things this week that used to give you some satisfaction, and see what happens to your mood."
Watch for: depression masking as "there's no point" about BDD work. Treat the hopelessness as a target, not a fact.

4.25 Family/carer involvement (young people; adapted for adults)

Purpose / when: NICE recommends that CBT including ERP for children and young people with BDD involve family or carers, with collaborative targets and rewards to build motivation. [source: NICE 1.5.1.10, 1.5.2.12–1.5.2.13] The manual covers adolescents as well as adults, but its specific family procedures are not drawn on [uncertain].
Steps: [synthesis] (1) Psychoeducation for family on the BDD cycle. (2) Identify accommodation: answering reassurance questions, buying camouflage products, allowing long bathroom time, funding procedures. (3) Agree a plan to reduce accommodation step by step, with supportive scripts. (4) Use rewards for exposure and ritual-prevention homework with young people.
Example language (illustrative, to parent): "When she asks if her skin looks bad, try saying 'I know this is the BDD worry. I'm not going to answer it, but I'm here with you.'"
Watch for: family conflict and hostility toward the symptoms. Coach a warm but firm tone.

4.26 Coordinating with medication and medical providers

Purpose / when: For moderate or severe impairment, or poor response. NICE offers SSRI or combined treatment, with a limited supply of medication when suicide risk is high, and multidisciplinary review after poor response. [source: NICE 1.5.1.6–1.5.1.7, 1.5.3.4, 1.5.4.1–1.5.4.2] Prescribing decisions belong to the prescriber; no dosing guidance is given here.
Steps: Discuss referral for medication review when impairment is severe, depression is marked, insight is delusional, or response is poor. Share the formulation with the prescriber and with dermatology or cosmetic providers (with consent). [synthesis based on NICE]
Example language (illustrative): "Many people do best with therapy and medication together. Would you be open to talking with a psychiatrist alongside our work?"
Watch for: the client seeing medication as proof they are "crazy". Frame it as reducing preoccupation, not as a judgment about their perception.

5. Handling problems

The manual has chapters on special considerations (ch. 3) and enhancing motivation (ch. 5), and a review notes that it addresses difficulty engaging, resistance and non-adherence. Their specific content is not drawn on [uncertain]. [source: Guilford ToC; EDR book review] Guidance below is tagged by origin.

Poor or absent insight ("It really is deformed"). Don't argue about the facts. Validate the distress and work on usefulness and costs instead of accuracy. Set goals around function. MI throughout. [source: IOCDF guide] Agree to "run the experiment" while disagreeing about the flaw. With delusional conviction, add a referral for medication review. [synthesis; NICE]
Client sees the problem as physical and wants a cosmetic fix. Use the cosmetic-treatment module: explore what the client expects the fix to change, weigh pros and cons without judgment, and review past procedures. [source: IOCDF guide] Ask the client to put new procedures on hold during treatment. [synthesis] If a procedure goes ahead mid-treatment, keep the client in treatment, re-assess risk afterwards, and examine whether preoccupation shifted. [synthesis]
Reassurance seeking directed at the therapist ("Be honest, does it look bad?"). Don't answer on content; either answer adds to the reassurance cycle. Name the pattern and link it to the model. [synthesis] Illustrative: "I notice the pull to get me to settle this. If I answer, it'll help for an hour and then the doubt comes back. What would it be like to sit with not knowing?"
Ideas of reference in session ("You looked at my nose"). Treat it as a hot thought to examine together, not as an accusation. Collaborative check: what did you see, what did you conclude, what else could explain it? [synthesis]
Camouflage in session (hat, heavy makeup, positioning in the room). Add these to the hierarchy and later use session time for exposure, e.g. sitting face-to-face in good light. [synthesis consistent with IOCDF exposure examples]
Overwhelm during exposure or mirror work. Drop to a lower hierarchy step. Shorten the duration but keep the no-ritual rule. Use perceptual retraining language to steady attention. Check for dissociation and risk. Reaffirm that it is voluntary. [source: IOCDF guide (start moderately); rest synthesis]
Homework non-adherence. Find out which kind it is: a skill gap (practise in session), task too big (break it down), avoidance (treat as an exposure target), or hopelessness or depression (depression module). [source: IOCDF guide (depression module); diagnostic split is synthesis] Assign homework that is specific and scheduled, and check it first each session.
Covert or substituted rituals. Check regularly for mental comparing, checking in shop windows or on the phone camera, and scanning faces for reactions. Add each new ritual to the tracking log and the delay/reduce plan. [synthesis based on IOCDF ritual list]
Stuck on automatic thoughts despite good restructuring. Move to the core belief with the downward arrow and the self-esteem pie, and step up behavioural experiments. Information gained by doing usually beats information gained by talking. [source: IOCDF guide; synthesis on emphasis]
Mirror avoidance rather than checking. Perceptual retraining applies here too, introduced gradually: brief whole-body practice at conversational distance, then building up. [source: IOCDF guide (avoiders named); grading is synthesis]
Rising suicide risk or crisis. Follow standard risk protocol: assess, update the safety plan including means safety, increase contact, and involve psychiatry or crisis services. Pause high-intensity exposure while risk is acute, then resume. NICE flags high risk in BDD, especially with poor response. [source: NICE 1.4.2.4, 1.5.4.9; app protocol escalation model; rest synthesis]
Severe depression blocking work. Bring the depression module forward: activity scheduling, then cognitive work. Consider a medication referral. [source: IOCDF guide; NICE]
Ruptures (client feels dismissed, "You think I'm vain", or feels you're saying they look fine). Acknowledge the misstep and restate that the distress is real and the target is suffering, not vanity. Re-agree the goals. Invite feedback at the end of sessions. [synthesis; validation stance from IOCDF guide]
Shame blocking disclosure (won't name the feature). Allow a gradual approach: write it down, point to it, or name it later. Normalise with psychoeducation. [synthesis; IOCDF notes concealment from shame]
Housebound or too ashamed to attend. Start by video or phone, and make attending in person an early hierarchy item. The team's app work shows remote, coach-supported delivery is feasible. [source: NCT03221738 protocol (remote format); adaptation is synthesis]
Picking causing injury, or DIY procedures. Arrange medical/dermatology care, raise the priority of the habit-reversal module, and assess risk. [synthesis]
Substance use (including anabolic steroids in muscle dysmorphia). Assess, refer for medical review, and include it in the formulation as a ritual or avoidance strategy where it fits. [synthesis; IOCDF lists substance use as a clue]
Family accommodation sustaining rituals. Use family sessions to agree a plan for reducing reassurance and accommodation (see 4.25). [source: NICE for young people; synthesis for adults]
Lapse after termination. Use the lapse-versus-relapse plan, restart self-therapy sessions, and book a booster. Restart the specific modules that slipped. [source: IOCDF guide; NCT03221738 protocol]
No response after an adequate course. Arrange multidisciplinary review and offer combined CBT and SSRI. Consider further CBT with a different team that has BDD expertise. [source: NICE 1.5.4.1–1.5.4.2, 1.5.4.8]

Sources

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