Cognitive Behavioral Therapy & Body Image

Millions of people share something in common. They’re preoccupied with their looks and see flaws in their appearance that others don’t see.

This may seem like nothing more than a bit of vanity. After all, most people are conscientious about how they look, and many are dissatisfied with some aspect of their appearance. But those who suffer from body dysmorphia, or distorted body image, are stuck in an all-consuming obsession that can significantly disrupt their lives.

What is Body Dysmorphic Disorder?

Body dysmorphic disorder (BDD) is a distinct mental health disorder characterized by intense obsession over some aspect of appearance. This obsession causes significant distress and interferes with daily life, including social events, family, and work.¹

Symptoms of BDD include:¹

• Being consumed with thoughts about your appearance
• Avoiding social situations
• Engaging in behaviors to fix or hide a disliked aspect of your appearance
• Believing that others notice the flaw in your appearance and ridicule you  
• Constantly seeking reassurance about your appearance

Often, those who suffer from BDD search endlessly for a physical solution for what is a disorder of the mind. BDD rarely improves on its own.

Co-Occurring Conditions

Body dysmorphic disorder can co-occur with other conditions, such as these:^2,3,4

• Depression
• Social phobia
• Obsessive-compulsive disorder (OCD)
• Substance abuse or substance use disorders
• Eating disorders

Emotions That Support a Distorted Body Image

A distorted body image involves a negative pattern of thinking that is highly self-critical. This constant internal criticism creates feelings of shame, guilt, and embarrassment. These feelings may prevent those suffering from distorted body image from seeking help.¹

Instead, they may become convinced that their deeply held assumptions and beliefs about themselves are accurate, which can lead to greater distress.¹

Cognitive Behavioral Therapy: A Dual Approach

Cognitive behavioral therapy (CBT) is a form of psychotherapy that focuses on changing harmful patterns of thinking or behavior. CBT treats various challenges, including anxiety, substance abuse, depression, and more.⁵ 

In CBT, the idea is that it’s not the event that creates our emotions. It’s how we interpret the event or the meaning that we give it. It emphasizes the critical role that thoughts (cognitive) and actions (behavioral) play in creating and maintaining belief systems.⁵

For instance, in body dysmorphic disorder, this may manifest in the following ways:

• Cognitive factors: negative body image, overly critical of appearance, and negative self-evaluation
• Behavioral factors: restricting food, body checking, trying to correct a physical flaw, and avoiding other people

Cognitive behavioral therapy helps to identify which thoughts and behaviors are playing a role in maintaining BDD and then works to address each one by teaching the skills necessary to allow healing to occur.

The Cognitive Component

The cognitive part of CBT works off these basic assumptions:⁶

• Thoughts affect emotions and behaviors.
• Psychological disorders, such as body dysmorphic disorder, involve flawed, inaccurate thoughts.
• Changes in thinking can lead to changes in emotions and behaviors.

Cognitive behavioral therapy helps individuals by identifying and changing those thoughts that are not accurate to create a different outcome.

The Behavioral Component

The behavioral part of CBT works off these basic assumptions:⁵

• Behaviors affect emotions and thoughts.
• Psychological disorders, such as body dysmorphic disorder, involve counterproductive behavior.
• Changes in dysfunctional behavior (such as through exposure to fears related to BDD) can lead to positive changes in emotions and thoughts.

Cognitive behavioral therapy helps people overcome difficulties by identifying and changing those behaviors that contribute to the formation and maintenance of destructive thoughts and emotions.

How CBT Can Change Body Image

Cognitive behavioral therapy uses thought-challenging (also known as cognitive restructuring) to disrupt negative thinking patterns that contribute to BDD.

This involves three basic steps:⁷ 

• Replacing harmful thoughts
• Identifying
• Challenging

1. Identify Negative Thoughts

With negative body image, physical appearance is given excessive importance in terms of self-worth. Those who suffer from body dysmorphic disorder may believe that a particular physical attribute defines them or casts them in such an unfavorable light that they are essentially worthless.

Recognizing these inaccurate perceptions is difficult once they take hold. An experienced therapist can facilitate this process to identify irrational and destructive thoughts.

2. Challenge Negative Thoughts

The next step in cognitive restructuring involves evaluating negative thoughts and then challenging them. This requires examining the evidence that supports the negative pattern of thinking. For instance, in distorted body image, people often believe a particular physical attribute will make them unpopular or disliked.

Strategies to challenge this idea include weighing the pros and cons of holding on to this belief and assessing the likelihood that this belief is true.

3. Replace Negative Thoughts With Positive Thoughts

Once negative thoughts have been identified and evaluated for their truthfulness, it is time to replace them with positive, productive thoughts that lead to a favorable outcome. This involves practice and dedication but has been demonstrated to be effective in breaking the cycle of negative thinking.⁷

CBT aims to be as objective and realistic as possible in interpreting situations that tend to trigger automated, negative thought patterns. By becoming more aware of the power of automated thoughts, the ability to interrupt them can be developed and utilized to overcome a wide range of destructive disorders, including body dysmorphic disorder.

CBT can also help change behaviors associated with BDD, such as checking mirrors and excessive grooming, by teaching the patient to monitor these behaviors and resist them.⁷

Patients may also learn skills that can help reduce anxiety around BDD, such as mindfulness and relaxation techniques.⁵

How to Hold Body Image Interventions

While poor body image is common, getting therapy for body image issues is not. Many people struggle for years before getting the help they need. As a concerned friend or family member, you could help someone get better. 

Listen 

If someone talks to you about their appearance, body shape, or weight, listen. It’s easy to jump in with a reassuring comment (e.g., “But I think you’re beautiful!”). But sometimes, the person just needs to talk. 

If you can, highlight the non-body-specific things you love about the person, just to steer the conversation in a more helpful direction.

Ask Questions

When someone begins talking about body image, dig a little deeper. Are they struggling with anxiety? Did someone at work or school say something unpleasant? Is a big deadline coming up?

Sometimes, body image issues stem from how people feel inside, not how they look. Your questions could make the connection clear. 

Highlight Solutions

If you know someone who is struggling with an eating disorder, it’s important to help them get treatment. Most eating disorders worsen the longer they go untreated and can become life-threatening.⁸

Talk with your doctor, a counselor, or a trusted therapist. Find out about treatment solutions in your area, and bring them up to your friend. Your homework can make entering treatment easier.