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Original Investigation
February 20, 2019

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

Author Affiliations
  • 1Department of Psychiatry, Massachusetts General Hospital, Boston
  • 2Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
  • 3Department of Psychiatry, Rhode Island Hospital, Providence
  • 4Department of Psychiatry, New York-Presbyterian Hospital, New York
  • 5Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
  • 6Department of Psychiatry, Weill Cornell Medical College, New York, New York
  • 7Mathematica Policy Research, Cambridge, Massachusetts
  • 8Department of Biostatistics, Massachusetts General Hospital, Boston
JAMA Psychiatry. 2019;76(4):363-373. doi:10.1001/jamapsychiatry.2018.4156
Key Points

Question  Is cognitive behavioral therapy for body dysmorphic disorder a more efficacious treatment than supportive psychotherapy for reducing body dysmorphic disorder symptom severity?

Findings  In this 2-site randomized clinical trial of 120 adults with primary body dysmorphic disorder, the difference in the efficacy between cognitive behavioral therapy for body dysmorphic disorder and supportive psychotherapy was site specific. The 2 treatments were comparable at 1 site, but cognitive behavioral therapy for body dysmorphic disorder achieved statistically significantly better results at the other site.

Meaning  Both treatments improved body dysmorphic disorder severity; however, cognitive behavioral therapy for body dysmorphic disorder reduced symptom severity more consistently across the 2 sites.


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