Efficacy and Posttreatment Effects of Cognitive Behavioral Therapy vs Supportive Psychotherapy for Body Dysmorphic Disorder | Obsessive-Compulsive and Related Disorders | JN Learning | AMA Ed Hub [Skip to Content]
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Efficacy and Posttreatment Effects of Therapist-Delivered Cognitive Behavioral Therapy vs Supportive Psychotherapy for Adults With Body Dysmorphic DisorderA Randomized Clinical Trial

Educational Objective
To determine whether cognitive behavioral therapy (CBT) for body dysmorphic disorder (BDD) is superior to supportive psychotherapy in reducing BDD symptom severity and associated BDD-related insight, depressive symptoms, functional impairment, and quality of life, and whether these effects are durable.
1 Credit CME
Key Points

Question  Is cognitive behavioral therapy for body dysmorphic disorder a more efficacious treatment than supportive psychotherapy for reducing body dysmorphic disorder symptom severity?

Findings  In this 2-site randomized clinical trial of 120 adults with primary body dysmorphic disorder, the difference in the efficacy between cognitive behavioral therapy for body dysmorphic disorder and supportive psychotherapy was site specific. The 2 treatments were comparable at 1 site, but cognitive behavioral therapy for body dysmorphic disorder achieved statistically significantly better results at the other site.

Meaning  Both treatments improved body dysmorphic disorder severity; however, cognitive behavioral therapy for body dysmorphic disorder reduced symptom severity more consistently across the 2 sites.

Abstract

Importance  Cognitive behavioral therapy (CBT), the best-studied treatment for body dysmorphic disorder (BDD), has to date not been compared with therapist-delivered supportive psychotherapy, the most commonly received psychosocial treatment for BDD.

Objective  To determine whether CBT for BDD (CBT-BDD) is superior to supportive psychotherapy in reducing BDD symptom severity and associated BDD-related insight, depressive symptoms, functional impairment, and quality of life, and whether these effects are durable.

Design, Setting, and Participants  This randomized clinical trial conducted at Massachusetts General Hospital and Rhode Island Hospital recruited adults with BDD between October 24, 2011, and July 7, 2016. Participants (n = 120) were randomized to the CBT-BDD arm (n = 61) or the supportive psychotherapy arm (n = 59). Weekly treatments were administered at either hospital for 24 weeks, followed by 3- and 6-month follow-up assessments. Measures were administered by blinded independent raters. Intention-to-treat statistical analyses were performed from February 9, 2017, to September 22, 2018.

Interventions  Cognitive behavioral therapy for BDD, a modular skills–based treatment, addresses the unique symptoms of the disorder. Supportive psychotherapy is a nondirective therapy that emphasizes the therapeutic relationship and self-esteem; supportive psychotherapy was enhanced with BDD-specific psychoeducation and treatment rationale.

Main Outcomes and Measures  The primary outcome was BDD symptom severity measured by the change in score on the Yale-Brown Obsessive-Compulsive Scale Modified for BDD from baseline to end of treatment. Secondary outcomes were the associated symptoms and these were assessed using the Brown Assessment of Beliefs Scale, Beck Depression Inventory–Second Edition, Sheehan Disability Scale, and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.

Results  Of the 120 participants, 92 (76.7%) were women, with a mean (SD) age of 34.0 (13.1) years. The difference in effectiveness between CBT-BDD and supportive psychotherapy was site specific: at 1 site, no difference was detected (estimated mean [SE] slopes, –18.6 [1.9] vs –16.7 [1.9]; P = .48; d growth-modeling analysis change, –0.25), whereas at the other site, CBT-BDD led to greater reductions in BDD symptom severity, compared with supportive psychotherapy (estimated mean [SE] slopes, –18.6 [2.2] vs –7.6 [2.0]; P < .001; d growth-modeling analysis change, –1.36). No posttreatment symptom changes were observed throughout the 6 -months of follow-up (all slope P ≥ .10).

Conclusions and Relevance  Body dysmorphic disorder severity and associated symptoms appeared to improve with both CBT-BDD and supportive psychotherapy, although CBT-BDD was associated with more consistent improvement in symptom severity and quality of life.

Trial Registration  ClinicalTrials.gov identifier: NCT01453439

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: October 5, 2018.

Corresponding Author: Sabine Wilhelm, PhD, Department of Psychiatry, Massachusetts General Hospital, 185 Cambridge St, Ste 2000, Boston MA 02114 (swilhelm@mgh.harvard.edu).

Published Online: February 20, 2019. doi:10.1001/jamapsychiatry.2018.4156

Correction: This article was corrected on April 3, 2019, to fix an error in an affiliation.

Author Contributions: Drs Wilhelm and Phillips had full access to all of the data and take full responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Wilhelm, Phillips, Greenberg, Keshaviah, Schoenfeld.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Wilhelm, Phillips, Greenberg, Hoeppner, Sarvode-Mothi.

Critical revision of the manuscript for important intellectual content: Wilhelm, Phillips, Greenberg, O'Keefe, Hoeppner, Keshaviah, Schoenfeld.

Statistical analysis: Wilhelm, Hoeppner, Keshaviah, Sarvode-Mothi, Schoenfeld.

Obtained funding: Wilhelm, Phillips, Keshaviah.

Administrative, technical, or material support: Wilhelm, Phillips, Greenberg, Keshaviah.

Supervision: Wilhelm, Phillips, O'Keefe, Keshaviah.

Conflict of Interest Disclosures: Dr Wilhelm reported being a presenter in educational programs for the Massachusetts General Hospital Psychiatry Academy supported through independent medical education grants from pharmaceutical companies; receiving royalties from Elsevier Publications, Guilford Publications, New Harbinger Publications, and Oxford University Press; receiving speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation and the Tourette Association of America; receiving payment from the Association for Behavioral and Cognitive Therapies as associate editor of the Behavior Therapy journal and from John Wiley & Sons Inc as associate editor of the Depression & Anxiety journal; and receiving salary support from Novartis and Telefonica Alpha Inc. Dr Phillips reported 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), American Society for Clinical Psychopharmacology (honorarium and travel funds for a presentation), American Psychiatric Association (honorarium for a presentation), B Braun Medical (travel funds), and from academic institutions (speaking honoraria and/or travel reimbursement). Dr Greenberg reported receiving salary support from Telefonica Alpha Inc and being a presenter in educational programs for the Massachusetts General Hospital Psychiatry Academy supported through independent medical education grants from pharmaceutical companies. No other disclosures were reported.

Funding/Support: This study was supported in part by grants R01MH091078 and R01 MH091023 from the National Institute of Mental Health Collaborative (Drs Wilhelm and Phillips), a grant from the Neil and Anna Rasmussen Research Fund (Dr Wilhelm), and a grant from the David Judah fund (Drs Phillips and Wilhelm).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3.

Additional Contributions: We wish to thank the following individuals for performing study ratings and/or providing administrative support: Susan Sprich, PhD, Anne Chosak, PhD, Jennifer Ragan, PhD, Hannah E. Reese, PhD, Angela Fang, PhD, Darin Dougherty, MD, Briana White, MA, Rebecca Swenson, PhD, William Lechner, PhD, Irina Kasarskis, MPH, Anne Wilson, MA, Rachel Schwartz, MA, Claire Nishioka, BA, Eliza Davidson, BS, Barbara Rosemberg, MHA, William Menard, BA, Joseph Donahue, BA, Richard Meza-Lopez, BA, Chloe Sarapas, BA, Martha A. Niemiec, BA, Kathleen Sullivan, BA, and Alicia Van Strander, BA; the following for providing study treatment: Johanna Malone, PhD, Jessica Rasmussen, PhD, Hilary Weingarden, PhD, Ashley S. Hart, PhD, Rachel Simmons, PhD, Elizabeth Didie, PhD, Lori Cragan, LCSW, Molly O'Brien, LCSW, and Jennifer Anthony, PhD; and the following for providing consultation on study tasks and procedures: Ulrike Buhlmann, PhD, Cary Savage, PhD, Gail Steketee, PhD, Sarah Mancuso, BA, and Janet Sherman, PhD. We also wish to thank the Data Safety and Monitoring Board members: Drs. Rebecca Betensky, Blair Simpson, and Stefan Hofmann. These individuals were financially compensated for their contributions.

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