Efficacy and Posttreatment Effects of Therapist-Delivered Cognitive Behavioral Therapy vs Supportive Psychotherapy for Adults With Body Dysmorphic Disorder: A Randomized Clinical Trial

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.

Figure 1.. Flow of Participants Through the Trial

Treatment completers were participants who completed 24 weeks of treatment regardless of whether they missed sessions or not. Site-specific numbers are provided at the end of each category. CBT-BDD indicates cognitive behavioral therapy for body dysmorphic disorder; M, Massachusetts General Hospital; R, Rhode Island Hospital; and SPT, supportive psychotherapy.

Figure 2.. Body Dysmorphic Disorder Symptom Severity Over Time by Treatment and Site

The Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS) mean scores decreased over time in the supportive psychotherapy (SPT) and cognitive behavioral therapy for body dysmorphic disorder (CBT-BDD) treatment arms from baseline to end of treatment (solid lines) and remained relatively unchanged during follow-up (dashed lines). Symptom severity of BDD decreased more in the CBT-BDD than supportive psychotherapy treatment arm at Rhode Island Hospital (RIH), but not at Massachusetts General Hospital (MGH). The lines shown are the model-based estimates of change over time in each treatment by site group, whereas the data points represent the raw means (SEs) of all available observations in each group at each time point. The data points based on raw data and the model-based linear trend estimates were offset from the actual week numbers in the graph to enable the visual discrimination of individual SE bars.

Figure 3.. Secondary Symptoms and Quality of Life Over Time by Treatment

All secondary symptoms (A-C) decreased from baseline to week 24 in supportive psychotherapy and cognitive behavioral therapy for body dysmorphic disorder (CBT-BDD) treatment arms, whereas quality of life increased (D). No treatment or site differences were found in the rate of change of lack of insight (Brown Assessment of Beliefs Scale score) and functional impairment (Sheehan Disability Scale) during treatment or follow-up. However, quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form) improved more in the CBT-BDD than the supportive psychotherapy treatment arm. No treatment or site differences were found in the rate of change in depression symptoms (Beck Depression Inventory-II [Beck Depression Inventory–Second Edition]) during treatment; however, participants in the CBT-BDD arm who completed end-of-treatment assessments (week 24) were significantly less depressed than participants in the supportive psychotherapy arm. No significant changes were observed in secondary symptoms or quality of life during follow-up (weeks 24 to 50). The solid lines (estimated slopes from the growth models of change during treatment) and dashed lines (estimated slopes from the growth models of change during follow-up) shown are the model-based estimates of change over time in each treatment by site group, whereas the data points represent the raw means (SEs) of all available observations in each group at each time point. The data points based on raw data and the model-based linear trend estimates were offset from the actual week numbers in the graph to enable the visual discrimination of individual SE bars. MGH indicates Massachusetts General Hospital; RIH, Rhode Island Hospital.