Cognitive-behavioral therapy for body dysmorphic disorder: a review of its efficacy

Figures & data

Table 1 Cognitive or behavioral treatment of BDD: controlled trials

References	Diagnostic criteria	Mean age and gender (%, female)	Duration of active treatment	Treatment	n	Y-BOCS-BDD scores pre → post treatment	Sig	BDDE scores pre → post treatment	Sig	Comments
Rosen et al^Citation36	DSM-III-R DSM-IV	36.5 ± 9.5 years; 100%	8 sessions per week; 2 hours each; total 8 weeks	CBGT Waiting list	27 27	NA NA	–	83.9 (14.8) → 41.1 (16.9) 89.9 (16.1) → 83.2 (19.7)	P < 0.001	CBGT significantly reduced BDD symptoms compared with the waiting list
Veale et al^Citation34	DSM-IV	35.4 ± NA years; 89.5%	1 session per week; duration NA; total 12 weeks	CBT Waiting list	9 10	22.0 (5.1) → 10.7 (9.7) 21.2 (7.2) → 24.3 (4.5)	P < 0.01	72.9 (17.0) → 42.4 (25.2) 91.3 (29.7) → 95.5 (11.4)	P < 0.01	CBT significantly reduced BDD symptoms compared with the waiting list
McKay et al^Citation37	DSM-III-R	31.2 ± 4.7 years; 60%	5 sessions per week; 90 minutes each; total 6 weeks	ERP + MP ERP − MP	5 5	31.1 (NA) → 9.1 (NA) 30.6 (NA) → 13. 2 (NA)	NS	NA NA	–	ERP improved BDD symptoms, but MP did not add further benefits
Khemlani- Patel et al^Citation41	DSM-IV	32.4 ± 10.5 years; 30%	3 sessions per week; 90 minutes each; total 8 weeks	CT + ERP ERP	NA (10)	27.8 (6.6) → 14.2 (6.3) 28.8 (3.7) → 18.2 (8.5)	NS	NA NA	–	ERP improved BDD symptoms, but CT plus ERP did not differ from ERP
Rabiei et al^Citation40	DSM-IV-TR	25.2 ± 6.5 years; 90%	8 sessions per week; 45–60 minutes each; total 8 weeks	MCT Waiting list	10 10	30.1 (6.5) → 20.1 (6.9) 30.8 (8.4) → 31.2 (8.6)	P < 0.005	NA NA	–	MCT significantly reduced BDD symptoms compared with the waiting list

Abbreviations: BDD, body dysmorphic disorder; CT, cognitive therapy; CBT, cognitive behavioral therapy; CBGT, cognitive behavioral group therapy; DSM, Diagnostic and Statistical Manual of Mental Disorders; ERP, exposure and response prevention; MP, maintenance program; MCT, metacognitive therapy; n, number of patients; NA, not available; NS, not significant; Y-BOCS-BDD, Yale-Brown Obsessive-Compulsive Scale modified for BDD; Sig, statistical significance; BDDE, Body Dysmorphic Disorder Examination.

Table 2 Cognitive or behavioral treatment for BDD: case series and open trials

References	Type of study	Diagnostic criteria	Age and gender (% female)	Duration of treatment	Treatment	n	Y-BOCSBDD scores pre → post treatment	Sig	General comments
Neziroglu and Yaryura- Tobias^Citation46	Case series	DSM-III-R	24.6 ± NA years; 60%	1–5 sessions per week, 90 minutes each (total 12–48 sessions)	Intensive CBT or weekly CBT	5	NA	NA	Authors note improvement of BDD symptoms (including overvalued ideas) in four patients
Wilhelm et al^Citation35	Case series	DSM-IV	30.6 ± 10.9 years; 76.9%	1 session per week, 90 minutes each (total 12 sessions)	CBGT	13	28.5 (NA) → 21.3 (NA)	t (7) = 3.6 P < 0.01	High levels of attrition (31%) were reported this sample
Saxena et al^Citation42	Case series	DSM-III-R	32.5 ± 8.5 years; 54.4%	6 weeks (other information NA)	Intensive CBT, medication, and psychosocial rehabilitation	11	29.6 (3.7) → 16.9 (5.1)	NA	BDD showed similar patterns of response to OCD. Authors note greater decreases in anxiety and depression in BDD than OCD
Neziroglu et al^Citation33	Open trial	DSM-III-R	25.1 ± 10.3 years; 58.8%	5 sessions per week, 90 minutes each (total 20 sessions)	Intensive CBT	17	25.7 (NA) → 12.0 (NA)	t (16) = 6.4 P < 0.001	OCD was present in 94% of this sample. Over 75% of the patients had more than four Axis II diagnoses
McKay et al^Citation37	Open trial	DSM-III-R	31.2 ± 4.7 years; 60%	5 sessions per week 90 minutes each (total NA)	ERP	10	31.1 (NA) → 9.1 (NA)	t (9) = 5.5 P < 0.001	Exposure was either in vivo or in imagery
Geremia and Neziroglu^Citation39	Open trial	DSM-IV	31.2 ± 4.5 years; 50%	2 sessions per week, 75 minutes each (total 30 sessions)	CT	4	25.2 (4.3) → 11.0 (3.9)	NA	High levels of compliance to assignments (100%) contrasts with the low compliance rates in the strictly behavioral treatment protocol
Wilhelm et al^Citation29	Open trial	DSM-IV	32.2 ± 4.6 years; 58%	1–2 sessions per week, 60 minutes each (total 18–22 sessions)	Modular CBT	12	32.9 (4.1) → 18.1 (11.7)	t (11) = 5.4 P < 0.001	More than 80% of those who began modular CBT completed it

Abbreviations: BDD, body dysmorphic disorder; NA, not available; CBT, cognitive behavioral therapy; CBGT, group cognitive behavioral therapy; CT, cognitive therapy; DSM, Diagnostic and Statistical Manual of Mental Disorders; n, number of patients; OCD, obsessive-compulsive disorder; OCS, obsessive-compulsive symptoms.

Table 3 Cognitive or behavioral treatment for BDD: meta-analysis

References	Treatment assessed	Studies analyzed (n)	Response
Williams et al^Citation31	Pharmacotherapy (clomipramine, fluvoxamine, fluoxetine, citalopram) and CBT (ERP; CT; ERP + CT)	15 studies Five pharmacological (1 RCT; 3 case series; 1 crossover) 10 CBT (2 RCT; 8 case series)	Both approaches were effective with small advantage of CBT in reduction of severity of BDD symptoms
Ipser et al^Citation32	Pharmacotherapy (clomipramine versus desipramine and fluoxetine versus placebo) and CBT (ERP; ERP + CT)	5 studies Two pharmacological (2 RCT) Three CBT (3 RCT)	Both approaches were effective, with no advantage of CBT. Differences in study design prohibited synthesis of data from pharmacotherapy trials

Abbreviations: n, number of samples; ERP, exposure and response prevention; CT, cognitive therapy; RCT, randomized controlled trial; CBT, cognitive behavioral therapy; BDD, body dysmorphic disorder.

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