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Abbarin M, Zemestani M, Rabiei M, Bagheri A. Efficacy of Cognitive-Behavioral Hypnotherapy on Body Dysmorphic Disorder: Case Study. IJPCP. 2018; 23 (4) :394-407
URL: http://ijpcp.iums.ac.ir/article-1-2522-en.html
1- MSc. in Clinical Psychology Department of Psychology, Faculty of Literature and Social Sciences, University of Kurdistan
2- . PhD in Psychology, Assistant Professor Department of Psychology, Faculty of Humanities and Social Sciences, University of Kurdistan , E-mail: m.zemestani@uok.ac.ir
3- PhD in Psychology, Assistant Professor Department of Psychology, Faculty of Medicine, Baqiyatallah University of Medical Sciences
4- Psychiatrist Branch of Hypnotherapy, Psychiatric Committee, Iranian Psychiatric Association
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Extended Abstract
1. Introduction

Patients with Body Dysmorphic Disorder (BDD) are preoccupied with imaginary defects in their appearances which bring about significant problems in important functioning areas [1].
According to the cognitive model of BDD, the progression of dysfunctional beliefs leads to rituals, avoidant behaviors, and negative thoughts. Negative emotions (e.g. fear, anxiety, and shame) activated by thoughts and negative beliefs, encourage efforts to neutralize these emotions through avoidant behavior and rituals. These rituals and avoidant behaviors can alleviate painful emotions temporally, but they are negatively reinforced and actually maintain the dysfunctional BDD beliefs and behaviors [3].
In clinical practice, patients with BDD are usually considered as resistant to treatment, and many fail to respond or even make a complete recovery [9]. Cognitive behavioral model of BDD emphasizes the role of imagination on maintenance of disorder [10-12]. Cognitive behavioral hypnotherapy assumes that the causes of most psychological disturbances are negative forms of self-hypnosis, in which negative thoughts are accepted without being criticized and even without conscious knowledge [13]. Hypnotherapy as an effective and complementary therapy is used for body image related disorders (eating disorders) [24, 25]. To the best of our knowledge, no research on the type of the effectiveness of interventions based on hypnosis has been performed on BBD.
The body image has mental, sensory, and body dimensions and studies support the increasing effectiveness of cognitive behavioral therapy in conjunction with hypnosis [27]. Hence, the present study was undertaken to determine the efficacy of cognitive behavioral hypnotherapy on BBD, depression, and disability of these patients.
2. Methods
In this article, we present a single subject experimental design with three baselines. The study population was patients with BBD in Sanandaj city. Purposive sampling was used, and after obtaining diagnostic interview and qualifications of the study, subjects underwent the treatment process. Two male and one female patient who were diagnosed with BBD and satisfied the inclusion criteria took part in the study. 
The Yale-Brown Obsessive Compulsive Scale modified for BBD (BDD-YBOCS), Beck Depression Inventory (DBI-II), Sheehan Disability Scale (SDS), Millon Clinical Multiaxial Inventory-III (MCMI-III), and clinical interview were used every week in baseline phase and twice a week in treatment condition at the beginning of each session. Cognitive-behavioral hypnotherapy was employed for 15 sessions of one and a half hours and for two sessions per week.
We used Wilhelm and colleagues’ manual of cognitive behavioral therapy for BBD [7] and Alladin’s cognitive hypnotherapeutic techniques [26] to develope the protocol for this study. This protocol was acknowledged by two specialist in hypnotherapy as well as the treatment BBD (third and fourth authors). For analysis of data, we used a single-case analysis using graphs and comparison of mean and median positions. The study was registered in Iranian Registry of Clinical Trials (IRCT) having code IRCT2016050425838N2. 
The first patient was a 30-year-old man. The main concern was the weak bones, hairs, and jaws, but he was pretty much preoccupied with all parts of his body. The second patient was a 31-year-old woman. Her main concern was her hair, and her way of walking and standing. The third patient was a 21-year-old man. His main concern was the nose, the sound, the parenthesis of the foot, and the hair.





 
3. Results
The results showed that the participants’ scores in BBD, depression, and disability decreased markedly. Two out of three patients (patient number 2 and 3) achieved the response to treatment criteria (≥30% reduction in BDD-YBOCS score from baseline) after treatment (50% and 37% reduction) and after four months follow-up (44% and 41% reduction) period. Patient number one was diagnosed with comorbid OCD and OCPD, and these may affect his treatment outcome (28% reduction) (Figure 1). In addition to improving the scores of BDD, the scores of disability and depression improved in all three patients. 
Participants’ scores in depression and disability significantly decreased in all patients after treatment (33%, 95%, and 89% reduction in depression scores and 22%, 72%, and 73% reduction in disability scores for patients 1, 2, and 3, respectively) and at follow-up period (18%, 33%, and 37% reduction in depression scores and 16%, 66%, and 78% reduction in disability scores for patients 1, 2, and 3, respectively). Figures 1 and 2 show a decrease in the scores in the treatment phase relative to the baseline period. The decrease in the follow-up period has also been relatively stable, and the level of change in the mean level is also evident.
4. Discussion
The present study reports the development and extension of the hypnotherapy supplementary protocol to cognitive-behavioral interventions for BBD. The results show proper efficacy in improving BBD, depression, and disability of these patients. Considering the benefits of hypnotherapy to improve BBD in patients as suggested in this study, it seems reasonable to incorporate hypnosis in cognitive-behavioral therapy for BBD.
The low number of participants and the compression of treatment protocol can be among the factors influencing the findings and the limitations of this research. Given the preliminary nature of this study and its single subject design, there is a need for further investigation in the future before generalizing the results. Moreover, the effect of variables such as hypnotizability of patients and comorbidities on the effectiveness of treatment should be considered for future investigations.
Acknowledgments
This research was extracted from the MSc. thesis of the first author in the Department of Psychology, Faculty of Literature and Social Sciences, University of Kurdistan, Sanandaj, Iran.
Conflict of Interest
The authors declare no conflicts of interest.
 
References
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[3]Wilhelm S, Phillips KA, Steketee G. Cognitive-behavioral treatment manual for Body Dysmorphic Disorder. New York: Guilford; 2013.

[4]Ipser JC, Sander C, Stein DJ. Pharmacotherapy and psychotherapy for Body Dysmorphic Disorder. Cochrane Database of Systematic Reviews. 2009; 1. doi: 10.1002/14651858.cd005332

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[7]Wilhelm S, Phillips KA, Didie E, Buhlmann U, Greenberg JL, Fama JM, Keshaviah A, Steketee G. Modular cognitive-behavioral therapy for Body Dysmorphic Disorder: A randomized controlled trial. Behavior Therapy. 2014; 45(3):314-27. doi: 10.1016/j.beth.2013.12.007

[8]Prazeres AM, Nascimento AL, Fontenelle LF. Cognitive-behavioral therapy for Body Dysmorphic Disorder: A review of its efficacy. Neuropsychiatric Disease and Treatment. 2013; 9:307. doi: 10.2147/ndt.s41074

[9]Willson R, Veale D, Freeston M. Imagery rescripting for Body Dysmorphic Disorder: A multiple-baseline single case experimental design. Behavior Therapy. 2016; 47(2):248–61. doi: 10.1016/j.beth.2015.08.006 

[10]Veale D. Advances in a cognitive behavioural model of Body Dysmorphic Disorder. Body Image. 2004; 1(1):113-25. doi: 10.1016/s1740-1445(03)00009-3

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[29]Phillips KA, Hart AS, Menard W. Psychometric evaluation of the Yale–Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS). Journal of Obsessive-Compulsive and Related Disorders. 2014; 3(3):205-8. doi: 10.1016/j.jocrd.2014.04.004

[30]Rabeie M. Khoramdel K. Kalantari M. Molavi H. [Factor structure, reliability and validity of Yale-Brown obsessive-compulsive scale modification of Body Dysmorphic Disorder among students (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2009, 2010; 15(4):343-350 

[31]Fata L, Birashk B, Atef-Vahid MK, Dobson KS. [Meaning assignment structures/ schemas, emotional states and cognitive processing of emotional information: Comparision of two conceptual frameworks (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2005; 11(3):312- 326. 

[32]Kaviani H. [Validity and reliability of hospital anxiety and depression scale (HADS), general health questionnaire (GHQ-28), Mood Adjectives Checklist, & BDI in clinical population in comparison with healthy group; Research report (Persian)]. Tehran: Tehran University of Medical Sciences; 2008.
 
[33]Sharifi AA, Molavi H, Namdari K. [The validity of MCMI-III (Millon) scales (Persian)]. Knowledge & Research in Applied Psychology. 2005; 9(34):27-38. 

[34]Sheehan DV, Harnett-Sheehan K, Raj BA. The measurement of disability. International Clinical Psychopharmacology. 1996; 11(3):89-95. doi: 10.1097/00004850-199606003-00015

[35]Amin-Esmaeili M, Motevalian A, Rahimi-Movaghar A, Hajebi A, Hefazi M, Radgoodarzi R, Sharifi V. The Translation and Psychometric Assessment of the Persian Version of the Sheehan Disability Scale. Iranian Journal of Psychiatry. 2014; 9(3):125-32. PMCID: PMC4277800

[36]Rush Jr J, First MB, Blacker D. Handbook of psychiatric measures. Arlington: American Psychiatric Publishing; 2007. 

[37]Neziroglu F, McKay D, Todaro J, Yaryura-Tobias JA. Effect of cognitive behavior therapy on persons with Body Dysmorphic Disorder and comorbid axis II diagnoses. Behavior Therapy. 1997; 27(1):67-77. doi: 10.1016/s0005-7894(96)80036-0 

[38]Veale D, Gournay K, Dryden W, Boocock A, Shah F, Willson R, Walburn J. Body Dysmorphic Disorder: a cognitive behavioural model and pilot randomised controlled trial. Behaviour Research and Therapy. 1996; 34(9):717-29. doi: 10.1016/0005-7967(96)00025-3

[39]McKay D, Todaro J, Neziroglu F, Campisi T, Moritz EK, Yaryura-Tobias JA. Body Dysmorphic Disorder: A preliminary evaluation of treatment and maintenance using exposure with response prevention. Behaviour Research and Therapy. 1997; 35(1):67-70. doi: 10.1016/s0005-7967(96)00082-4 

[40]Geremia GM, Neziroglu F. Cognitive therapy in the treatment of Body Dysmorphic Disorder. Clinical Psychology & Psychotherapy. 2001; 8(4):243-51. doi: 10.1002/cpp.284 

[41]Rosen JC, Reiter J, Orosan P. Cognitive-behavioral body image therapy for Body Dysmorphic Disorder. Journal of Consulting and Clinical Psychology. 1995; 63(2):263-69. doi: 10.1037//0022-006x.63.2.263

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Type of Study: Original Research | Subject: General
Received: 2016/06/21 | Accepted: 2017/05/20

References
1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). Arlington: American Psychiatric Association Publish-ing; 2013.
2. Phillips KA. Quality of life for patients with Body Dysmorphic Disorder. The Journal of Nervous and Mental Disease. 2000; 188(3):170-5. doi: 10.1097/00005053-200003000-00007 [DOI:10.1097/00005053-200003000-00007]
3. Wilhelm S, Phillips KA, Steketee G. Cognitive-behavioral treatment manual for Body Dysmorphic Disorder. New York: Guilford; 2013.
4. Ipser JC, Sander C, Stein DJ. Pharmacotherapy and psychotherapy for Body Dysmorphic Disorder. Cochrane Database of Systematic Reviews. 2009; 1. doi: 10.1002/14651858.cd005332 [DOI:10.1002/14651858.CD005332]
5. Wilhelm S, Phillips KA, Fama JM, Greenberg JL, Steketee G. Modular cognitive–behavioral therapy for Body Dysmorphic Disorder. Behavior Therapy. 2011; 42(4):624-33. doi: 10.1016/j.beth.2011.02.002 [DOI:10.1016/j.beth.2011.02.002]
6. Williams J, Hadjistavropoulos T, Sharpe D. A meta-analysis of psychological and pharmacological treatments for Body Dysmorphic Disorder. Behaviour Research and Therapy. 2006; 44(1):99-111. doi: 10.1016/j.brat.2004.12.006 [DOI:10.1016/j.brat.2004.12.006]
7. Wilhelm S, Phillips KA, Didie E, Buhlmann U, Greenberg JL, Fama JM, Keshaviah A, Steketee G. Modular cognitive-behavioral therapy for Body Dys-morphic Disorder: A randomized controlled trial. Behavior Therapy. 2014; 45(3):314-27. doi: 10.1016/j.beth.2013.12.007 [DOI:10.1016/j.beth.2013.12.007]
8. Prazeres AM, Nascimento AL, Fontenelle LF. Cognitive-behavioral therapy for Body Dysmorphic Disorder: A review of its efficacy. Neuropsychiatric Dis-ease and Treatment. 2013; 9:307. doi: 10.2147/ndt.s41074 [DOI:10.2147/NDT.S41074]
9. Willson R, Veale D, Freeston M. Imagery rescripting for Body Dysmorphic Disorder: A multiple-baseline single case experimental design. Behavior Thera-py. 2016; 47(2):248–61. doi: 10.1016/j.beth.2015.08.006 [DOI:10.1016/j.beth.2015.08.006]
10. Veale D. Advances in a cognitive behavioural model of Body Dysmorphic Disorder. Body Image. 2004; 1(1):113-25. doi: 10.1016/s1740-1445(03)00009-3 [DOI:10.1016/S1740-1445(03)00009-3]
11. Neziroglu F, Khemlani-Patel S, Veale D. Social learning theory and cognitive behavioral models of Body Dysmorphic Disorder. Body Image. 2008; 5(1):28-38. doi: 10.1016/j.bodyim.2008.01.002 [DOI:10.1016/j.bodyim.2008.01.002]
12. Veale D, Neziroglu F. Body Dysmorphic Disorder: A treatment manual. Hoboken, New Jersey: John Wiley & Sons; 2010. [DOI:10.1002/9780470684610]
13. Araoz DL. The new hypnosis. New York: Brunner-Mazel; 1985.
14. Golden WL, Dowd ET, Friedberg F. Hypnotherapy: A modern approach. Oxford: Pergamon Press; 1987.
15. Alladin A, Amundson J. Cognitive hypnotherapy as a transdiagnostic protocol for emotional disorders. International Journal of Clinical and Experimental Hypnosis. 2016; 64(2):147-66. doi: 10.1080/00207144.2016.1131585 [DOI:10.1080/00207144.2016.1131585]
16. Alladin A. Cognitive hypnotherapy: A new vision and strategy for research and practice. American Journal of Clinical Hypnosis. 2012; 54(4):249-62. doi: 10.1080/00029157.2012.654528 [DOI:10.1080/00029157.2012.654528]
17. Alladin A. Healing the wounded self: Combining hypnotherapy with ego state therapy. American Journal of Clinical Hypnosis. 2013; 56(1):3-22. doi: 10.1080/00029157.2013.796282 [DOI:10.1080/00029157.2013.796282]
18. Alladin A. The wounded self: New approach to understanding and treating anxiety disorders. American Journal of Clinical Hypnosis. 2014; 56(4):368-88. doi: 10.1080/00029157.2014.880045 [DOI:10.1080/00029157.2014.880045]
19. Brown DP, Fromm E. Hypnotherapy and hypnoanalysis. Abingdon: Routledge; 1986.
20. Ewin DM, Eimer BN. Ideomotor signals for rapid hypnoanalysis: A How-to-manual. Sangamon County, Illinois: Charles C Thomas Publisher; 2006.
21. Watkins JG, Barabasz A. Advanced hypnotherapy: Hypnodynamic techniques. Abingdon: Routledge; 2007.
22. Watkins JG. The affect bridge: A hypnoanalytic technique. International Journal of Clinical and Experimental Hypnosis. 1971; 19(1):21-7. doi: 10.1080/00207147108407148 [DOI:10.1080/00207147108407148]
23. Yapko MD. Trancework: An introduction to the practice of clinical hypnosis. Abingdon: Routledge; 2012.
24. Barabasz AF, Watkins JG. Hypnotherapeutic techniques. Abingdon: Routledge; 2005.
25. Hammond DC. Hypnotic induction & suggestion. Bloomingdale, Illinois: American Society of Clinical Hypnosis; 1998.
26. Alladin A, Alibhai A. Cognitive hypnotherapy for depression: an empirical investigation. International Journal of Clinical and Experimental Hypnosis. 2007; 55(2):147-66. doi: 10.1080/00207140601177897 [DOI:10.1080/00207140601177897]
27. Kirsch I, Montgomery G, Sapirstein G. Hypnosis as an adjunct to cognitive-behavioral psychotherapy: A meta-analysis.Consulting and Clinical Psycholo-gy. 1995; 63(2):214-20. doi: 10.1037//0022-006x.63.2.214 [DOI:10.1037//0022-006X.63.2.214]
28. Phillips KA. An open-label study of escitalopram in Body Dysmorphic Disorder. International Clinical Psychopharmacology. 2006; 21(3):177-9. doi: 10.1097/01.yic.0000194378.65460.ef [DOI:10.1097/01.yic.0000194378.65460.ef]
29. Phillips KA, Hart AS, Menard W. Psychometric evaluation of the Yale–Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS). Journal of Obsessive-Compulsive and Related Disorders. 2014; 3(3):205-8. doi: 10.1016/j.jocrd.2014.04.004 [DOI:10.1016/j.jocrd.2014.04.004]
30. Rabeie M. Khoramdel K. Kalantari M. Molavi H. [Factor structure, reliability and validity of Yale-Brown obsessive-compulsive scale modification of Body Dysmorphic Disorder among students (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2009, 2010; 15(4):343-350
31. Fata L, Birashk B, Atef-Vahid MK, Dobson KS. [Meaning assignment structures/ schemas, emotional states and cognitive processing of emotional infor-mation: Comparision of two conceptual frameworks (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2005; 11(3):312- 326.
32. Kaviani H. [Validity and reliability of hospital anxiety and depression scale (HADS), general health questionnaire (GHQ-28), Mood Adjectives Checklist, & BDI in clinical population in comparison with healthy group; Research report (Persian)]. Tehran: Tehran University of Medical Sciences; 2008.
33. Sharifi AA, Molavi H, Namdari K. [The validity of MCMI-III (Millon) scales (Persian)]. Knowledge & Research in Applied Psychology. 2005; 9(34):27-38.
34. Sheehan DV, Harnett-Sheehan K, Raj BA. The measurement of disability. International Clinical Psychopharmacology. 1996; 11(3):89-95. doi: 10.1097/00004850-199606003-00015 [DOI:10.1097/00004850-199606003-00015]
35. Amin-Esmaeili M, Motevalian A, Rahimi-Movaghar A, Hajebi A, Hefazi M, Radgoodarzi R, Sharifi V. The Translation and Psychometric Assessment of the Persian Version of the Sheehan Disability Scale. Iranian Journal of Psychiatry. 2014; 9(3):125-32. PMCID: PMC4277800 [PMID] [PMCID]
36. Rush Jr J, First MB, Blacker D. Handbook of psychiatric measures. Arlington: American Psychiatric Publishing; 2007.
37. Neziroglu F, McKay D, Todaro J, Yaryura-Tobias JA. Effect of cognitive behavior therapy on persons with Body Dysmorphic Disorder and comorbid axis II diagnoses. Behavior Therapy. 1997; 27(1):67-77. doi: 10.1016/s0005-7894(96)80036-0 [DOI:10.1016/S0005-7894(96)80036-0]
38. Veale D, Gournay K, Dryden W, Boocock A, Shah F, Willson R, Walburn J. Body Dysmorphic Disorder: a cognitive behavioural model and pilot random-ised controlled trial. Behaviour Research and Therapy. 1996; 34(9):717-29. doi: 10.1016/0005-7967(96)00025-3 [DOI:10.1016/0005-7967(96)00025-3]
39. McKay D, Todaro J, Neziroglu F, Campisi T, Moritz EK, Yaryura-Tobias JA. Body Dysmorphic Disorder: A preliminary evaluation of treatment and maintenance using exposure with response prevention. Behaviour Research and Therapy. 1997; 35(1):67-70. doi: 10.1016/s0005-7967(96)00082-4 [DOI:10.1016/S0005-7967(96)00082-4]
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