J. Behav. Ther. & Exp. Psychiat.

40 (2009) 580–582

Contents lists available at ScienceDirect

Journal of Behavior Therapy

and Experimental Psychiatry
journal homepage: www.elsevier.com/locate/jbtep

Book review

Overcoming Body Image Problems Including Body Dysmorphic Disorder, D. Veale, R. Willson,
A Clarke. Robinson, London (2009). p. 403, ISBN: 9781845292799

In recent years, there has been growing interest in the broad field of body image problems among
researchers and clinicians. In 2006, The National Institute for Health and Clinical Excellence (NICE)
issued clinical guidelines (NICE, 2006) regarding assessment and treatment of body dysmorphic
disorder (BDD). As regards psychological treatment, cognitive behavior therapy (CBT) is considered to
be the treatment of choice for persons suffering from BDD. As for non-clinical body image dissatis-
faction, there is also sound research findings in support of CBT (e.g., Butters & Cash, 1987; Dworkin &
Kerr, 1987).
This badly needed self-help book on BDD and body image problems truly seems like a gift from
above delivered none too early. David Veale, Rob Willson, and Alex Clarke have interlaced research
findings with their own clinical experiences into an easily comprehensible text that has been eagerly
awaited.
By way of introduction, the book describes appearance as a general concept by linking it to how
cultural factors influence the way in which people attach importance to their looks. Setting out from
a diagnostic definition of BDD, the book also deals with common differential diagnoses as well as
frequent comorbid conditions associated with BDD and body image problems. You will also find
a discussion on the development of body image dissatisfaction with regard to possible etiological
factors. Several proposed maintenance factors are described, where intrusive thoughts, distorted
perceptual bias, self-focused attention, thought suppression, mental images, fusion of thoughts and
reality, brooding and worrying, rituals, body shame, as well as overt avoidance and safety behaviors are
highlighted.
Naturally, this self-help book is primarily focused on the psychological treatment of BDD. Inter-
estingly, the book indeed points out a truly integrative approach. Firmly establised in cognitive
behavioral theory, the subsequent chapters on treatment encompasses various empirically supported
techniques, ranging from the first to the third generation of behavior therapy. The chapters on treat-
ment draw on essential components from acceptance and commitment therapy (ACT; Hayes, Strosahl,
& Wilson, 1999) in combination with more ’’traditional’’ CBT techniques. As regards ACT, you will find
features such as defusion, acceptance, metaphors, and valued directions exercises. As for more tradi-
tional CBT, there are instructions to performing behavioral experiments, graded exposure tasks, verbal
skills training, and role-playing exercises. Included are also an exercise drawn from imagery rescripting
(e.g., Holmes, Arntz, & Smucker, 2007) and a few exercises devised by psychologists Adrian Wells,
Windy Dryden, and Sandra Bogels, respectively.
As has been reported elsewhere, diverse CBT models of BDD have been proposed (e.g., Rabi-
nowitz, Neziroglu, & Roberts, 2007; Veale, 2004; Veale et al., 1996) ranging from pure behavioral
models to more integrated cognitive behavioral models. A case in point is a recent review article
written by Neziroglu, Khemlani-Patel, and Veale (2008), in which two contemporary CBT models
are highlighted as seen from their disparate theoretical foundations. In this review article, David

doi:10.1016/j.jbtep.2009.08.002
 Book review / J. Behav. Ther. & Exp. Psychiat. 40 (2009) 580–582 581

Veale emphasizes information processing (e.g., mental imagery, self-focused attention, meta-
cognitions, negative appraisals) in addition to basic principles of negatively reinforced avoidance
and safety-seeking behaviors. On the other hand, Fugen Neziroglu and Sony Khemlani-Patel
propound modern behavior analytic theories as means for understanding BDD, and in line with this
they also propose that ACT should be evaluated as a treatment for BDD. In the present self-help
book, techniques derived from these two CBT models coalesce naturally without giving a picture of
a dichotomy or a quarrel between these two schools of thought.
The book also offers quite intensive training in the functional analytic approach, which is taught by
means of several self-monitoring records, charts, and behavioral experiment sheets. It contains plenty
of questionnaires and fill-in exercises, which serve the purpose of aiding you through the self-help
program.
Besides, the authors describe six fictitious case reports, where each case has its own body image
problem outlined. A brief description of each case is followed by a summary of how the psychological
treatment was carried out and how it turned out. Furthermore, there is a chapter on compulsive skin-
picking, which is often associated with body image problems. There is also a chapter on general
guidelines for relatives. Another chapter deals with aspects of requesting cosmetic surgery, and yet
another chapter is about medication. In this latter there is plenty of information concerning when
medication may be suggested, how different types of medication are believed to work, and also lots of
information concerning common side effects.
Considering the acute shortage of self-help books that are explicitly tailor-made for BDD, this
one must be regarded as an important and unique contribution not only for those suffering but
also for others interested in these indeed handicapping conditions. The authors’ warm, competent,
and encouraging tone of voice seems like an approach worthy of imitation for clinicians and
researchers out there. But like most other self-help books, this one can be criticized for its absence
of empirical data in support of the self-help program. To date, as far as I know, no trial has ever
investigated CBT for BDD when delivered as bibliotherapy. However, since this book builds on
empirically supported cognitive behavioral techniques that have proven effective in the self-help
treatment of body image problems (e.g., Cash & Lavallee, 1997; Grant & Cash, 1995; Strachan &
Cash, 2002), it is to be hoped that people suffering from BDD, in particular, will benefit from
reading and working with this book.
Although written as a self-help guide, the fifteen chapters of the book altogether constitute
a tremendous resource for clinicians, researchers, students and not least the relatives of sufferers. To
my mind, this book is really a must for those interested!

References

Butters, J. W., & Cash, T. F. (1987). Cognitive-behavioral treatment of women’s body-image dissatisfaction. Journal of Consulting
and Clinical Psychology, 55, 889–897.
Cash, T. F., & Lavallee, D. M. (1997). Cognitive-behavioral body-image therapy: extended evidence of the efficacy of a self-
directed program. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 15, 281–294.
Dworkin, S. H., & Kerr, B. A. (1987). Comparison of interventions for women experiencing body image problems. Journal of
Counseling Psychology, 34, 136–140.
Grant, J. R., & Cash, T. F. (1995). Cognitive-behavioral body image therapy: comparative efficacy of group and modest-contact
treatments. Behavior Therapy, 26, 69–84.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An experiential approach to behavior
change. New York: Guilford.
Holmes, E. A., Arntz, A., & Smucker, M. R. (2007). Imagery rescripting in cognitive behaviour therapy: images, treatment
techniques and outcomes. Journal of Behavior Therapy and Experimental Psychiatry, 38, 297–305.
National Institute for Health and Clinical Excellence (NICE). (2006). Obsessive-compulsive disorder: Core interventions in the
treatment of obsessive-compulsive disorder and body dysmorphic disorder. National Clinical Practice Guideline Number 31.
Northamptonshire: The British Psychological Society and The Royal College of Psychiatrists.
Neziroglu, F., Khemlani-Patel, S., & Veale, D. (2008). Social learning theory and cognitive behavioral models of body dysmorphic
disorder. Body Image, 5, 28–38.
Rabinowitz, D., Neziroglu, F., & Roberts, M. (2007). Clinical application of a behavioral model for the treatment of body dys-
morphic disorder. Cognitive and Behavioral Practice, 14, 231–237.
Strachan, M. D., & Cash, T. F. (2002). Self-help for a negative body image: a comparison of components of a cognitive-behavioral
program. Behavior Therapy, 33, 235–251.
Veale, D. (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image, 1, 113–125.
582 Book review / J. Behav. Ther. & Exp. Psychiat. 40 (2009) 580–582

Veale, D., Gournay, K., Dryden, W., Boocock, A., Shah, F., Willson, R., et al. (1996). Body dysmorphic disorder: a cognitive
behavioural model and pilot randomised controlled trial. Behaviour Research and Therapy, 34, 717–729.

Iman Alaie
M.Sc. Program in Clinical Psychology, Department of Psychology,
Uppsala University, Box 1225, SE-75142 Uppsala, Sweden
E-mail address: imanalaie@gmail.com