Novel Therapy Promising for Body Dysmorphic Disorder

Pauline Anderson

February 05, 2016

Therapist-guided, Internet-based cognitive-behavioral therapy (CBT) is superior to online supportive therapy in improving symptoms of body dysmorphic disorder (BDD), new research shows.

Online CBT may offer a more accessible and less costly therapy for patients with BDD, according to lead author Jesper Enander, clinical psychologist and doctoral candidate in the Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.

"It seems to be a promising option for many BDD sufferers who currently don't have access to evidence-based treatment," he told Medscape Medical News.

The study was published online February 2 in the BMJ.

Prohibitive Treatment Costs

BDD is a psychiatric disorder characterized by a pervasive preoccupation with perceived defects in physical appearance accompanied by compulsive behaviors, such as mirror gazing and excessive camouflaging to hide perceived defects.

CBT that focuses on key features of BDD is recommended as treatment, but costs can be prohibitive and availability limited.

The new, single-blinded, parallel-group study included 94 adults diagnosed with mostly moderate BDD according to DSM-5 diagnostic criteria. Patients scored at least 20 on the modified Yale- Brown Obsessive-Compulsive Scale (BDD-YBOCS).

Patients were randomly assigned to receive either an online CBT program tailored to BDD called BDD-NET or online supportive therapy, a type of talk-based therapy.

BDD-NET includes eight interactive modules, each covering a different theme. The main intervention is a systematic exposure to fear-eliciting situations or events combined with response prevention until anxiety and urges to ritualize, such as compulsive mirror checking, subside.

To progress to the next module, patients must complete homework assignments, examples of which include reading text material, answering a quiz, filling out worksheets, and practicing exposure or response prevention. Throughout the program, participants have contact with a therapist, whose role is to guide, coach, and provide feedback.

Confidentiality is ensured through an authentication login function.

The supportive therapy employed talk therapy and counseling techniques, such as reflecting, empathizing, and summarizing, said Enander. It was chosen as a control because it is the most common type of psychotherapy that BDD patients would be likely to receive in the "real world."

Participants in this group had unlimited access to a therapist and could talk freely about their experiences, thoughts, and feelings concerning their condition and how it affected their life. The therapist sent an email at least once a week encouraging the participants to discuss distressing life events and to promote problem-solving.

"The supportive therapy group mainly talked about their experiences and problems, as you do in that kind of therapy, while the CBT group did daily exercises that were aimed at reducing anxiety and compulsive behaviors," he said.

Both therapies continued for 12 weeks, and both groups were followed for 3 months after the end of treatment, for a total of 6 months from baseline. Supportive-therapy patients were offered BDD-Net after the 6-month follow-up.

Assessors were masked to treatment allocation at baseline and at the 3- and 6-month follow-ups.

Better Quality of Life

The primary outcome was change in severity of BDD symptoms, as assessed by a clinician using the BDD-YBOCS. Scores on that scale can range from 0 to 48, with a higher score indicating a more severe disorder.

The investigators found that online CBT was superior to supportive therapy. The standardized effect sizes between groups were large at both time points: 0.95 (95% confidence interval [CI], 0.52 - 1.38) at 3 months and 0.87 (95% CI, 0.42 - 1.31) at 6 months.

The effect size within groups at 6 months was 1.42 (95% CI, 0.95 - 1.89) for BDD-NET and 0.55 (95% CI, 0.13 - 0.96) for supportive therapy.

Depressive symptoms, as assessed with the Montgomery-Åsberg Depression Rating Scale–Self-report, decreased with online CBT but not with supportive therapy. There was a significant difference between groups at both follow-up times.

With online CBT, there was an increase in function, as assessed with the Global Assessment of Functioning scale and the Clinical Global Impressions–Improvement scale (CGI-I), but this was not the case for supportive therapy.

As for health-related quality of life, there was no significant difference between groups at 3 months. However, at 6 months, the quality of life had improved in patients receiving BDD-NET, and there was a significant difference between groups, favoring BDD-NET.

The proportion of participants classified as responders (defined as a greater than 30% reduction in scores on the BDD-YBOCS) was significantly higher in the online CBT group at both 3 months (54% vs 6%) and 6 months (56% vs 3%).

At 6 months, 56% of the BDD-NET group were classified as improved or much improved on the CGI-I; for the supportive therapy group, 16% saw improvement.

The number of participants no longer meeting criteria for BDD (so classified as being in remission) was 32% vs 2% at 3 months and 39% vs 9% at 6 months, again favoring CBT.

No serious adverse events related to the therapies were reported during the study.

Although severity of BDD in study participants ranged from mild to severe, for safety reasons, researchers excluded patients with some severe psychiatric symptoms.

"Our data show that participants with severe BDD can benefit from BDD-NET, but what we don't know is if it's safe to include participants with severe suicidal ideation or a history of bipolar disorder or psychosis," said Enander

Although the study showed that online CBT was better than online supportive therapy, it is not clear whether it is superior to CBT delivered in the office setting.

"Further studies will be needed to establish the equivalence or noninferiority of Internet-based CBT against gold-standard, face-to-face CBT for BDD," he said.

There might be several advantages to online CBT. For example, it could offer a cost-effective and accessible alternative (particularly in rural areas) to in-office therapy, especially when trained therapists are be available.

"BDD-NET may be particularly useful in a stepped-care approach, where mild to moderate cases can be offered online CBT by the general practitioner or other health professionals, thus freeing resources for more severe and complex cases to be treated in specialized settings," said Enander.

He added that this online approach has been incorporated into the healthcare systems in Sweden, Australia, and the Netherlands.

Currently, only a small minority of BDD patients receive CBT at all. In the United States, only an estimated 17% of such patients receive this therapy; in Germany, fewer than 10% do.

The research team is planning a trial of an English version of the program in the United States in collaboration with Hofstra University and Harvard Medical School.

"If the English version of BDD-NET is shown to be efficacious, our hope is that the treatment can be made available to patients globally," said Enander.

Welcome Research

Commenting on the findings for Medscape Medical News, Katharine Phillips, MD, professor of psychiatry and human behavior, Warren Alpert Medical School of Brown University, and director, Body Dysmorphic Disorder Program, Rhode Island Hospital, Providence, described the study as "important."

"BDD is severe, causes a lot of suffering, and is very common, affecting about 2% of the population. It is also an 'unrecognized' disorder that is much less studied than other serious mental disorders. So any treatment study is really welcome," she said.

Dr Phillips has focused on BDD since the early 1990s. She and her colleagues have developed a CBT therapy for BDD and have published a treatment manual.

Internet-based CBT might be an especially useful option for BDD patients, said Dr Phillips. "Patients with this disorder are often so ashamed at how they look, so self-conscious, that they don't want to go out very much, and some are housebound because they don't want anyone to see them."

She thought it was "excellent" that study participants had access to a therapist. Each participant received a mean of 13 minutes of therapist time weekly, which is less than with face-to-face therapy. Nevertheless, "it's a meaningful amount of time," said Dr Phillips.

Although she found the study "exciting and interesting" and believes that its results support CBT as an efficacious therapy for BDD, Dr Phillips did have a number of caveats.

One is that, although the response rate for CBT was better than for supportive therapy in the study, "it wasn't all that high."

She also thought that the remission rate, which she felt "was very generously defined and included a lot of people I might not consider remitted," could have been better.

"Studies of medication alone and other studies of CBT have, for the most part, found notably higher response rates," as high as in the 70% or even higher.

In addition to therapist-administered CBT, BDD is typically treated with serotonin reuptake inhibitors, often at relatively high doses, said Dr Philips.

This higher response rate could be due to the in-person setting or because the studies were longer. Dr Phillip's own research of CBT in BDD showed the response rate at 12 weeks to be similar to that in the study but "continued to climb" after patients were treated for another 3 months.

She also noted that the follow-up period in the study was only 3 months post treatment, which might be too brief. "A lot of studies do a 6-month or 1-year follow-up," she said.

Dr Phillips stressed that the typical patient with BDD is "pretty severely ill" and so might not quality for Internet-based CBT.

"We have to keep in mind that many people with BDD have suicidal thinking, attempt suicide, and complete suicide," and they often have depressive symptoms. They thus represent a high-risk population who need in-person monitoring.

Before she would recommend this type of therapy to patients, she said that she "would want to make sure they had no suicidality, which is common in BDD, so you're ruling out a lot of people right there. And I would want to make sure the depression isn't worrisome, that it's mild or maybe in the moderate range."

She also noted that the study appeared to include a high proportion of patients with good insight, whereas a lot of BDD patients have poor or absent insight.

"They are completely convinced that they look abnormal. Many want cosmetic procedures, such as surgery or dermatologic treatment, and a lot of them need a therapist just to get them motivated to even do treatment."

The authors have disclosed no relevant financial relationships.

BMJ. Published online February 2, 2016. Full text

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