Comparing CBT to Supportive Therapy for Treatment of Body Dysmorphic Disorder

Supportive psychotherapy is the most common psychosocial treatment for body dysmorphic disorder (BDD). However, even though BDD can severely impair mood, functioning and quality of life, the use of supportive psychotherapy to treat BDD has never been formally evaluated.

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Sabine Wilhelm, PhD, program director for the Obsessive-Compulsive Disorder and Related Disorders Program at Massachusetts General Hospital, David Schoenfeld, PhD, researcher with the Biostatistics Center at MGH, and colleagues recently conducted the largest-ever study of BDD treatment, a randomized trial to compare supportive psychotherapy with cognitive behavioral therapy (CBT) tailored to BDD. Symptoms improved with both types of therapy, they report in JAMA Psychiatry, but CBT was associated with more consistent improvement in symptom severity and quality of life.

Study Design

The researchers studied 120 adults (77% female, 83% non-Hispanic white, mean age 34) with BDD between October 24, 2011, and July 7, 2016, at Mass General and Rhode Island Hospital. Patients had to have a score of at least 24 on the clinician-administered Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS), which indicates moderate severity.

The patients were randomly assigned to 22 hour-long sessions of one of the manual-based treatments:

• CBT: Treatment included psychoeducation, case formulation, setting valued goals, motivational enhancement, cognitive restructuring, exposure and ritual prevention, and mindfulness and attentional retraining. It also focused on advanced strategies to modify self-defeating assumptions about the importance of appearance and to enhance self-acceptance, self-esteem and self-compassion

• Supportive psychotherapy: Nondirective treatment aimed to help patients learn to cope with external and psychological challenges. The therapy focused on maintaining, improving and restoring self-esteem and adaptive coping skills, as well as expressing emotions about current life issues

Outcomes were assessed by independent evaluators who were blinded to treatment assignment.

Primary Outcome

BDD symptom severity, assessed with the BDD-YBOCS, decreased significantly throughout treatment in both groups. However, by the end of treatment, BDD symptoms had decreased significantly more with CBT than with supportive psychotherapy.

Among patients who finished the study, the response rates were:

• CBT: 84.6% at Mass General and 83.3% at Rhode Island Hospital
• Supportive psychotherapy: 69.2% at Mass General and 45.5% at Rhode Island Hospital

Secondary Outcomes and Durability of Response

Depressive symptoms, BDD-related insight, quality of life and functional impairment improved in both groups from baseline to week 24. The only significant difference between treatment groups was that improvement in quality of life was greater with CBT. Attendance and the number of dropouts were similar in the two groups.

Over six months of follow-up, the gains made during therapy were equally durable in the two groups.

Adverse Events

There were no serious adverse events (e.g., suicide attempts). Two of 61 participants in the CBT group and four of 59 participants in the supportive psychotherapy group reported at least one adverse event that was considered possibly related to study treatment, including increased depression (CBT, one; supportive psychotherapy, three), increased anxiety (CBT, one; supportive psychotherapy, one) and increased obsessive-compulsive disorder symptoms (supportive psychotherapy, two).

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