CBT Bests Anxiety Management for Body Dysmorphic Disorder

By Deborah Brauser
Medscape Medical News
June 27, 2014

LONDON—Cognitive–behavioral therapy (CBT) may be the most effective treatment for patients with body dysmorphic disorder (BDD), including those with comorbid depression, new research suggests.

In what the investigators note is the first study to compare this treatment against another psychological intervention, results showed that outpatients who received CBT for 12 weeks had significantly greater improvement scores on all BDD measures assessed, including the Yale–Brown Obsessive Compulsive Scale for BDD (BDD–YBOCS), than their counterparts who received anxiety management.

In addition, the CBT group showed further benefits after 4 weeks of additional treatment.

"Both treatments had the same amount of therapists'time and homework, but showed different results,"lead author David Veale, MD, FRCPsych, consultant psychiatrist at the Institute of Psychiatry at King's College London and at the South London and Maudsley National Health Service Foundation Trust, told Medscape Medical News.

"It's gratifying to know that we are getting somewhere, but we do understand that this is a very tricky population to treat,"added Dr. Veale.

The results were presented here at the International Congress of the Royal College of Psychiatrists (RCPsych) 2014.

Past Research "Weak"

According to the researchers, the evidence base for CBT's effectiveness in BDD has been weak, "with 4 trials of CBT against a wait list, of which at least 2 were unrepresentative."

Dr. David Veale

For this study, they sought to examine whether the treatment was more effective than a credible, although nonspecific, alternative for those with BDD.

A total of 46 outpatients with BDD were enrolled and were randomly assigned to receive for 12 weeks either CBT, based on techniques discussed in a treatment manual coauthored by Dr. Veale (n = 21), or anxiety management (n = 25).

The primary outcome measure was score change from baseline to the 12–week mark on the BDD–YBOC. Secondary measures included the Body Image Quality of Life Inventory (BIQLI), the Appearance Anxiety Inventory (AAI), and the Brown Assessment of Beliefs (BABS).

Further analysis examined the effects of an extra 4 weekly sessions of CBT, as well as whether the therapy was effective in those with comorbid depression and delusional BDD.

Results showed that CBT was "significantly superior over time to anxiety management on the BDD–YBOCS (score change, 12.01 vs 4.81, respectively; P less than .01). It was also superior on the BABS (score change, 5.49 vs 1.01), the AAI (12.28 vs 4.41), and the BIQLI (0.54 vs -0.36).

"A main effect of time predicted BDD–YBOCS and AAI scores [and] a main effect of treatment group predicted BIQLI scores," added the investigators.

Advances the Field?

Although the CBT group showed significantly decreased scores at the 12–week mark across all the measures assessed, the anxiety management group showed significant decreases only on the BDD– YBOCS and AAI measures.

In addition, 48% of those receiving CBT vs 12% of those receiving anxiety management were found to be treatment responders, defined as having a BDD–YBOCS score decrease from baseline of at least 30% (P = .01). Recovery was maintained for all responders at the 1–month follow–up.

Having comorbid delusional beliefs or depression made no difference on outcomes. "Therefore, CBT should not be regarded as only suitable for those with good insight or who are not depressed," write the researchers.

Overall, "the results support previous studies regarding the effectiveness of CBT for BDD, but also advances the field as the current study included an active psychological treatment that was compared against CBT," they add.

They note that the optimal length of CBT treatment appears to be at least 16 weeks (with sessions administered on a weekly basis).

Study limitations that were cited included the short follow–up period and the fact that the study was conducted at only 1 center. In addition, "further research is required to determine the generalizability of the findings in other settings, such as in adolescents, and augmenting CBT with a selective serotonin reuptake inhibitor (SSRI)."

Dr. Veale noted that this may be especially elucidating because augmenting therapy with an SSRI has been shown to be beneficial for people with obsessive–compulsive disorder. In addition, he would like future research to assess whether CBT is helpful for all people with BDD or whether it works better for those with a severe form of the disorder.

He added that it is important to remember that this population is very hard to treat. "Even after 12 weeks, we only helped about 50% of the people."

"Important Study"

"This is a very important study because BDD is a severe and common disorder whose treatment has been only minimally studied," Katharine Phillips, MD, director of the BDD Program at Rhode Island Hospital in Providence, told Medscape Medical News.

Dr. Katharine Phillips

"There is a great need to develop and test treatments for BDD because patients suffer tremendously, are usually very impaired in terms of their functioning, and can commit suicide because of their appearance concerns."

Dr. Phillips, who is also a professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University, was not involved with this research.

She noted that although CBT that specifically targets BDD symptoms can help this patient population, "in our experience, many patients require more than 16 sessions." And although she applauds this study overall, Dr. Phillips said that she has 2 key questions:

First, were medications held stable for at least several months before and during the study? "Certain medications, specifically the serotonin–reuptake inhibitors, usually improve BDD."

And second, will the effects of the treatment last beyond a month after the treatment ends?

Dr. Veale is coauthor of a treatment manual for BDD and of a self–help guide for body image problems "using cognitive'behavioral techniques." Dr. Phillips reported that she and her colleagues have developed a CBT treatment for BDD.

International Congress of the Royal College of Psychiatrists (RCPsych) 2014. Poster 18. Presented June 24, 2014.