Modular Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Randomized Controlled Trial

doi:10.1016/j.beth.2013.12.007

Behavior Therapy

Volume 45, Issue 3, May 2014, Pages 314-327

https://doi.org/10.1016/j.beth.2013.12.007 Get rights and content

Highlights

•
Examined feasibility, acceptability, and treatment outcome of modular cognitive behavioral therapy for BDD (CBT-BDD) in 36 BDD patients.
•
At post-treatment, BDD and related symptoms (e.g., mood) were significantly improved.
•
Treatment gains were maintained at 6-month follow-up.

Abstract

There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). CBT-BDD utilizes core elements relevant to all BDD patients (e.g., exposure, response prevention, perceptual retraining) and optional modules to address specific symptoms (e.g., surgery seeking).

Thirty-six adults with BDD were randomized to 22 sessions of immediate individual CBT-BDD over 24 weeks (n = 17) or to a 12-week waitlist (n = 19). The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Brown Assessment of Beliefs Scale, and Beck Depression Inventory–II were completed pretreatment, monthly, posttreatment, and at 3- and 6-month follow-up. The Sheehan Disability Scale and Client Satisfaction Inventory (CSI) were also administered. Response to treatment was defined as ≥ 30% reduction in BDD-YBOCS total from baseline. By week 12, 50% of participants receiving immediate CBT-BDD achieved response versus 12% of waitlisted participants (p = 0.026). By posttreatment, 81% of all participants (immediate CBT-BDD plus waitlisted patients subsequently treated with CBT-BDD) met responder criteria. While no significant group differences in BDD symptom reduction emerged by Week 12, by posttreatment CBT-BDD resulted in significant decreases in BDD-YBOCS total over time (d = 2.1, p < 0.0001), with gains maintained during follow-up. Depression, insight, and disability also significantly improved. Patient satisfaction was high, with a mean CSI score of 87.3% (SD = 12.8%) at posttreatment. CBT-BDD appears to be a feasible, acceptable, and efficacious treatment that warrants more rigorous investigation.

Section snippets

Participants

Participants consisted of 36 adults (61% female) age 18 or older with primary DSM-IV BDD (based on symptom severity). Potential participants were screened initially by phone for BDD and were invited for an in-person assessment if they met eligibility criteria. Participants were recruited with flyers and brochures posted in the community and mailed to clinicians (e.g., mental health professionals, dermatologists, plastic surgeons) in the surrounding areas from August 2005 to December 2008.

Descriptive Characteristics at Study Baseline

Baseline characteristics including demographics, medication use, and comorbidity for the CBT-BDD and waitlist groups are presented in Table 1. Participants reported the following primary appearance concerns: face (n = 6), hair (n = 6), skin (n = 6), stomach (n = 6), nose (n = 3), body build (n = 2), face profile (n = 2), cheeks (n = 1), chest (n = 1), pectoral muscles/torso (n = 1), hips (n = 1), and weight (n = 1). Additional areas of concern reported by at least 50% of participants at baseline included: hair (81%),

Discussion

In this study, we examined the efficacy of CBT-BDD relative to a waitlist control condition in adults with BDD. Results from this study are consistent with prior research and advance the literature in several ways. The high response rate after 22 sessions of treatment (81%–83%) is similar to that reported in our open trial of this new treatment in which 75% of the ITT sample and 80% of treatment completers were responders based on the BDD-YBOCS criterion (Wilhelm et al., 2011). Consistent with

Conflict of Interest Statement (past 3 years)

Drs. Wilhelm, Phillips, and Steketee report receiving royalties from Guilford Press for a treatment manual on body dysmorphic disorder (BDD). In addition, we have the following disclosures, which are not directly relevant for this project. Drs. Wilhelm, Phillips, and Steketee receive royalties from Oxford University Press. Drs. Wilhelm and Steketee receive royalties from New Harbinger Publications. Drs. Wilhelm and Phillips receive support in the form of free medication and matching placebo

References (54)

U. Buhlmann et al.
Updates on the prevalence of body dysmorphic disorder: A population-based survey
Psychiatry Research
(2010)
M.B. Cororve et al.
Body dysmorphic disorder: A review of conceptualizations, assessment, and treatment strategies
Clinical Psychology Review
(2001)
J.L. Eisen et al.
Insight in obsessive compulsive disorder and body dysmorphic disorder
Comprehensive Psychiatry
(2004)
E.B. Foa
Failure in treating obsessive-compulsives
Behavior Research and Therapy
(1979)
E.B. Foa et al.
Feared consequences, fixity of belief, and treatment outcome in patients with obsessive-compulsive disorder
Behavior Therapy
(1999)
J.L. Greenberg et al.
Cognitive-behavioral therapy for adolescent body dysmorphic disorder
Cognitive and Behavioral Practice
(2010)
K. Horowitz et al.
Body dysmorphic disorder in an adolescent girl
Journal of the American Academy of Child and Adolescent Psychiatry
(2002)
D. McKay et al.
Body dysmorphic disorder: A preliminary evaluation of treatment and maintenance using exposure with response prevention
Behaviour Research and Therapy
(1997)
F. Neziroglu et al.
Predictive validity of the overvalued ideas scale: Outcome in obsessive-compulsive and body dysmorphic disorders
Behaviour Research and Therapy
(2001)
K.A. Phillips
Psychosis in body dysmorphic disorder
Journal of Psychiatric Research
(2004)

K.A. Phillips et al.

Clinical features of body dysmorphic disorder in adolescents and adults

Psychiatry Research

(2006)

K.A. Phillips et al.

Treating body dysmorphic disorder with medication: Evidence, misconceptions, and a suggested approach

Body Image: An International Journal of Research

(2008)

B.O. Rothbaum et al.

The assessment of trichotillomania

Behaviour Research and Therapy

(1994)

D. Veale

Advances in a cognitive behavioural model of bodydysmorphic disorder

Body Image

(2004)

D. Veale et al.

Body dysmorphic disorder: A cognitive behavioural model and pilot randomised controlled trial

Behaviour Research and Therapy

(1996)

S. Wilhelm et al.

A cognitive-behavioral treatment approach for body dysmorphic disorder

Cognitive and Behavioral Practice

(2010)

S. Wilhelm et al.

Cognitive theory of body dysmorphic disorder

S. Wilhelm et al.

Cognitive behavior group therapy for body dysmorphic disorder: a case series

Behaviour Research and Therapy

(1999)

S. Wilhelm et al.