Therapist-guided, Internet-delivered cognitive behaviour therapy for adolescents with body dysmorphic disorder: A feasibility trial with long-term follow-up

Efficacy of an internet-based, therapist-guided cognitive behavioral therapy intervention for adolescents and young adults with body dysmorphic disorder: a randomized controlled trial

BACKGROUND

Body dysmorphic disorder (BDD) is particularly prevalent yet highly understudied and undertreated in adolescence. This study evaluates the efficacy of an internet-based, therapist-guided cognitive behavioral therapy (CBT) for adolescents and young adults with BDD compared to supportive online therapy as an active control condition.

METHODS

In a single-blind, randomized controlled trial, N = 45 adolescents (aged 15-21 years) of all genders from German-speaking countries were assigned to 12 sessions of internet-based CBT (iCBT) or 12 weeks of supportive online therapy. The primary outcome was change in expert-rated BDD symptom severity from pre- to post-intervention (Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder, BDD-YBOCS). Secondary outcomes included the remission and responder rate, changes in delusionality of appearance beliefs (BABS), self-rated BDD symptom severity (FKS), BDD cognitions (FKDK), quality of life (KINDL-R), and depressive symptoms (PHQ-9) from pre to post and to a 4-week follow-up.

RESULTS

iCBT was more efficient than supportive online therapy on the BDD-YBOCS (p =.002), with a large between-group effect size at post-intervention (Hedges' g (SE) = 0.93 (0.42)), and on all secondary measures (p <.05), except for depressive symptoms (p =.068). All secondary outcome measures also showed significant improvements from pre to post iCBT, with moderate to large effect sizes, and gains were stable until the 4-week follow-up period. iCBT participants showed higher remission (61.5%) and responder rates (66.7%), compared to controls (0% and 26.7%), but only the difference in remission reached significance.

CONCLUSION

The results indicate the efficacy of internet-based CBT in comparison to an active control condition, thus contributing to the limited intervention research in adolescent BDD and adding a much-needed treatment option.

TRIAL REGISTRATION

The trial was pre-registered on 2020/06/08 at the German Clinical Trials Register, DRKS00022055.

Long-term outcomes of smartphone-delivered cognitive behavior therapy for body dysmorphic disorder: A one-year naturalistic follow-up

Background

Body dysmorphic disorder (BDD) is an often chronic and impairing psychiatric condition. Research shows that smartphone-delivered cognitive behavior therapy (CBT) with coaching may be a scalable and effective treatment for BDD. However, evidence for long-term gain maintenance is limited.

Objectives

The aim of the current study was to examine the long-term outcomes of a smartphone-based CBT for BDD.

Method

Adults with a primary diagnosis of BDD who completed a 12-week course of smartphone-delivered CBT with coach support were evaluated 3- and 12-months posttreatment. Symptom severity, remission and responder status were assessed with the clinician-rated Yale-Brown Obsessive-Compulsive Scale modified for BDD (BDD-YBOCS). Secondary outcomes were also evaluated and included BDD-related insight, depression, functioning and quality of life. Data were analyzed using four different approaches to missing data, with maximum likelihood estimation as the main approach.

Results

There was significant attrition from posttreatment (n = 57) to 3-month (n = 49) and 12-month (n = 33) follow-up. The mean BDD-YBOCS severity score remained stable during the follow-up period [Estimated Mean (SE) at posttreatment, 3-months, and 12-months = 18.7(1.1), 18.9(1.2) and 18.8(1.3), respectively]. The proportion of participants responding to treatment and in remission remained relatively unchanged as well (63 % responders and 46 % remitters at posttreatment, 54 % and 35 % at 3-month follow-up, and 61 % and 37 % at 12-month follow-up, respectively). Posttreatment gains in BDD-related insight, functioning, and quality of life were maintained; there were small increases in depression (ES = 0.36) from posttreatment to 12-month follow-up.

Conclusions

Improvements after coach-supported smartphone-based CBT for BDD are maintained one year after treatment.

Body dysmorphic disorder

Body dysmorphic disorder (BDD) is an obsessive-compulsive disorder-related psychiatric condition characterized by an intense preoccupation with perceived physical flaws that are not observable by others. BDD affects ~2% of the adult population but is underdiagnosed, partly owing to limited clinician awareness, and undertreated, partly due to limited access to treatment. Research on the aetiology of BDD is scarce but likely involves an interplay between genetic and environmental factors. A few studies suggest functional and structural brain differences (compared with controls) in the regions involved in visual and emotional processing, although firm conclusions about the pathophysiology of the disorder cannot be made at this stage. Diagnosis requires the presence of repetitive behaviours or mental acts typically aimed at checking, correcting or concealing perceived flaws. The disorder typically has its onset before 18 years of age, with a female preponderance in youth but no major gender disparity in adults. Quality of life is markedly impaired across multiple domains and suicide risk is considerable. Evidence-based treatments include cognitive behavioural therapy and selective serotonin reuptake inhibitors. Future research should focus on understanding the biological and environmental factors that increase the risk of BDD, and on improving access to effective treatments, thereby addressing a critical gap in care for this often misunderstood and overlooked disorder.

The use of coaching in smartphone app-based cognitive behavioral therapy for body dysmorphic disorder

Background

Body dysmorphic disorder (BDD) is severe and undertreated. Digital mental health could be key to expanding access to evidence-based treatments, such as cognitive behavioral therapy for BDD (CBT-BDD). Coach guidance is posited to be essential for effective uptake of digital interventions. However, little is known about how different patients may use coaching, what patterns correspond to meaningful outcomes, and how to match coaching to patient needs.

Methods

Participants were 77 adults who received a 12-week guided smartphone CBT-BDD. Bachelor's-level coaches were available via asynchronous messaging. We analyzed the 400 messages sent by users to coaches during treatment. Message content was coded using the efficiency model of support (i.e., usability, engagement, fit, knowledge, and implementation). We aimed to clarify when and for what purposes patients with BDD used coaching, and if we can meaningfully classify patients by these patterns. We then assessed potential baseline predictors of coach usage, and whether distinct patterns relate to clinical outcomes.

Results

Users on average sent 5.88 messages (SD = 4.51, range 1-20) and received 9.84 (SD = 5.74, range 2-30). Regarding frequency of sending messages, latent profile analysis revealed three profiles, characterized by: (1) peak mid-treatment (16.88 %), (2) bimodal/more communication early and late in treatment (10.39 %), and (3) consistent low/no communication (72.73 %). Regarding content, four profiles emerged, characterized by mostly (1) engagement (51.95 %), (2) fit (15.58 %), (3) knowledge (15.58 %), and (4) miscellaneous/no messages (16.88 %). There was a significant relationship between frequency profile and age, such that the early/late peak group was older than the low communication group, and frequency profile and adherence, driven by the mid-treatment peak group completing more modules than the low contact group. Regarding content, the engagement and knowledge groups began treatment with more severe baseline symptoms than the fit group. Content profile was associated with dropout, suggesting higher dropout rates in the miscellaneous/no contact group and reduced rates in the engagement group. There was no relationship between profile membership and other outcomes.

Discussion

The majority of participants initiated little contact with their coach and the most common function of communications was to increase engagement. Results suggest that older individuals may prefer or require more support than younger counterparts early in treatment. Additionally, whereas individuals using coaching primarily for engagement may be at lower risk of dropping out, those who do not engage at all may be at elevated risk. Findings can support more personalized, data-driven coaching protocols and more efficient allocation of coaching resources.