A Randomized Clinical Trial Comparing Cognitive Behavioral Therapy vs Supportive Psychotherapy to Treat Body Dysmorphic Disorder

Publisher: JAMA Psychiatry (online ahead of print)
Feb 20, 2019
Authors
Sabine Wilhelm, Katharine A. Phillips, Jennifer L. Greenberg, Sheila M. O’Keefe, Susanne S. Hoeppner, Aparna Keshaviah, Suraj Sarvode-Mothi, and David A. Schoenfeld

Key Findings:

  • Body dysmorphic disorder severity decreased significantly over the course of treatment in both arms and at both sites.
  • Compared with supportive psychotherapy, cognitive behavioral therapy led to greater reductions in symptom severity and greater improvements in quality of life at one of the two sites studied.
  • Depression severity, functional impairment and body dysmorphic disorder-related insight decreased significantly over time in both arms, with no differences by treatment type or by site.
  • No significant changes were detected in post-treatment symptom severity over the course of the 6 month follow-up period.

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.