CBT Bests Supportive Psychotherapy for Body Dysmorphic Disorder

Megan Brooks

February 26, 2019

Both therapist-delivered cognitive-behavioral therapy (CBT) and supportive psychotherapy (SPT) ease severity and associated symptoms of body dysmorphic disorder (BDD), but CBT leads to more consistent improvement, results of the first randomized head-to-head comparison show.

"This is the biggest therapy study that's been done in BDD but also the first to compare the recommended form of therapy, CBT, with the most widely used therapy, SPT, and to do it in person, not online," Katharine Phillips, MD, psychiatrist at New York–Presbyterian/Weill Cornell Medicine in New York City, told Medscape Medical News.

On the basis of the results, she would recommend CBT for BDD (CBT-BDD) over SPT used with a treatment manual shown to be effective, Phillips said.

The study was published online February 20 in JAMA Psychiatry.

First Large-Scale Trial

BDD affects an estimated 3% of the general population. It's 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.

The efficacy of CBT-BDD has been demonstrated in six randomized clinical trials, with response rates from 48% to 82%.

However, previous trials of CBT-BDD were limited by small, restrictive samples, the investigators point out in their article. In addition, until now, therapist-delivered CBT-BDD had not been compared with therapist-delivered SPT, the most common psychosocial treatment for BDD.

The trial was conducted at two centers, Massachusetts General Hospital (MGH) and Rhode Island Hospital (RIH), and included 120 adults (92 women, mean age, 34 years).

All participants had received a primary diagnosis of BDD on the basis of DSM-IV criteria and had a score of 24 or higher on the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS), which indicates illness of moderate severity.

Sixty-one participants were randomly allocated to receive CBT-BDD; 59 were allocated to received SPT. Patients underwent weekly treatment sessions for 24 weeks, followed by 3- and 6-month follow-up assessments.

CBT-BDD is a modular skills–based treatment that addresses symptoms of the disorder. SPT is a nondirective therapy that emphasizes the therapeutic relationship and self-esteem and is enhanced with BDD-specific psychoeducation and treatment rationale.

The primary outcome was BDD symptom severity, measured by change in score on the BDD-YBOCS from baseline to end of treatment, as well as change in associated symptoms, as assessed with the Brown Assessment of Beliefs Scale, the Beck Depression Inventory–Second Edition, the Sheehan Disability Scale, and the Quality of Life Enjoyment and Satisfaction Questionnaire–Short Form.

Between-Site Differences

Both treatments led to improvement in BDD symptom severity from baseline to week 24 (primary outcome), as indicated by scores on the BDD-YBOCS, although there were some site-specific differences.

At MGH, there was no difference in effectiveness of CBT-BDD and SPT (estimated mean slopes: –18.6 vs –16.7; P = .48). At RIH, CBT-BDD led to greater reductions in BDD symptom severity compared with SPT (estimated mean slopes: –18.6 vs –7.6; P < .001).

"Differences in therapists' training and experience were confounded with site effects and could have contributed to the observed variability in the effectiveness of supportive psychotherapy," the investigators write.

At week 24, overall response rates with CBT-BDD were 84.6% (22 of 26) at MGH and 83.3% (15 of 18) at RIH. For SPT, overall response rates were 69.2% (18 of 26) at MGH and 45.5% (10 of 22) at RIH.

CBT-BDD and SPT also led to improvements in depressive symptoms, BDD-related insight, quality of life, and functional impairment from baseline to week 24, but the change in quality-of-life scores was statistically significantly greater for CBT-BDD than SPT.

The gains made in treatment were maintained through 6-month follow-up. Both treatments were well tolerated, and adverse events were minimal.

"Across the two study sites, CBT was more consistently effective at reducing BDD symptom severity and improving quality of life, while the outcome was more variable with supportive therapy," said Phillips.

"Our hypothesis was that CBT would be more effective, and in some ways our hypothesis was confirmed, although we did not expect the difference across the two sites. The good news is that the majority of patients improved, but the response rates were higher in the CBT group," said Phillips.

The current results support a prior study in which therapist-guided Internet-based CBT was superior to online SPT in improving BDD symptoms, as reported by Medscape Medical News.

The investigators indicate that it's important to note that the cohort was predominantly female and well educated and so may not be fully representative of the BDD population. Also, study participants received an enhanced form of SPT, which may have been better than SPT that is typically provided in community practice. This would likely have bolstered outcomes.

"Additional studies of BDD treatment are needed, especially large studies that examine the transportability of these treatments to real-world settings, such as community mental health centers," they conclude.

"Strong Evidence"

In an accompanying editorial, Douglas Mennin, PhD, from Columbia University in New York City, writes that the study "advances the field" through rigorous testing of a manualized CBT-BDD protocol against an established comparator.

"The trial is well-powered and controlled with sophisticated randomization and blinding procedures," Mennin writes.

The results provide "strong evidence" for the utility of CBT-BDD for ameliorating BDD dysfunction after treatment, with maintenance of gains through 6 months, Mennin notes.

"Important next steps for ensuring durable outcomes for the most people will be determining the essential elements for clinically significant improvement and how these elements produce change for different patients," he concludes.

The study was supported in part by grants from the National Institute of Mental Health Collaborative, the Neil and Anna Rasmussen Research Fund, and the David Judah fund. Phillips reports receiving royalties from Oxford University Press, American Psychiatric Publishing, UpToDate, International Creative Management Inc, and Guilford Press, as well as support from Merck Manual (honoraria), the American Society for Clinical Psychopharmacology (honorarium and travel funds for a presentation), the American Psychiatric Association (honorarium for a presentation), B Braun Medical (travel funds), and from academic institutions (speaking honoraria and/or travel reimbursement). Mennin has disclosed no relevant financial relationships.

JAMA Psychiatry. Published online February 20, 2019. Abstract, Editorial

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