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Caponnetto P, Caramazza M, Caci G, Signorelli MS, Petralia A, Quattropani MC. Body dysmorphic disorder and psychotherapeutic interventions: a systematic literature review. Health Psychol Res 2024; 12:117649. [PMID: 38883698 PMCID: PMC11176052 DOI: 10.52965/001c.117649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 05/09/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Body dysmorphism disorder (BDD) is a disabling mental disorder characterized by an anxious preoccupation with a perceived defect in physical appearance. Objective This systematic review arose with the main objective of identifying the most effective psychotherapeutic intervention in the treatment of BDD. Methods From February to October 2022, we conducted a systematic review aimed at identifying the psychotherapeutic intervention for BDD, the search for these concepts was on PubMed. There were no language limitations, only time limitations, we delved into studies published in the databases between 2015 and 2022. Results We identified a total of 393 unique records. Of these, 43 full-text articles were evaluated for eligibility, and seven of these met the inclusion criteria and were included in the final systematic review. Conclusions Cognitive-behavioral therapy has been shown to be effective compared with other therapies, especially when combined with drug therapy. The results confirm that BDD-NET (INTERNET-based CBT) led to significant improvement of symptoms in patients with body dysmorphism. In conclusion, we can say that cognitive-behavioral therapy, whether in direct or online form, appears to be the most effective treatment for this disorder.
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Affiliation(s)
- Pasquale Caponnetto
- Department of Educational Sciences, Section of Psychology, University of Catania, 95123 Catania, Italy
- Center of Excellence for the Acceleration of Harm Reduction (CoEHAR), University of Catania, 95121 Catania, Italy
| | - Manila Caramazza
- Department of Educational Sciences, Section of Psychology, University of Catania, 95123 Catania, Italy
| | - Grazia Caci
- Department of General Surgery and Medical-Surgical Specialities, University of Catania, Catania, Italy.Infectious Disease Department at University Hospital AOU Policlinico "G. Rodolico- San Marco" of Catania, Italy
| | - Maria S Signorelli
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, 95123 Catania, Italy
| | - Antonino Petralia
- Department of Clinical and Experimental Medicine, Psychiatry Unit, University of Catania, 95123 Catania, Italy
| | - Maria C Quattropani
- Department of Educational Sciences, Section of Psychology, University of Catania, 95123 Catania, Italy
- Center of Excellence for the Acceleration of Harm Reduction (CoEHAR), University of Catania, 95121 Catania, Italy
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Applewhite B, Olivola M, Tweed C, Wesemann U, Himmerich H. Body dysmorphic disorder, muscle dysmorphia, weight and shape dissatisfaction and the use of appearance-enhancing drugs in the military: a systematic review. BMJ Mil Health 2024; 170:255-266. [PMID: 35675995 DOI: 10.1136/bmjmilitary-2022-002135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/16/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Body dysmorphic disorder (BDD) and muscle dysmorphia (MD) are common but often underdiagnosed disorders. These disorders have rarely been explored in the context of military personnel by mental health researchers despite the emphasis on physical fitness in military populations. We conducted a comprehensive systematic literature review on scientific studies of BDD and MD and the accompanying symptoms within the military. METHODS We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and used PubMed, Web of Science and PsycINFO as databases with "body dysmorphic disorder," "muscle dysmorphia," "body image," "performance and image enhancing drugs," "anabolic steroid," military personnel," "soldiers," "navy," "air force," "army" and "armed forces" as search terms. RESULTS A total of 20 eligible articles reporting data of 42 952 study participants were used. According to the identified literature, prevalence rates of BDD in the military are ~10% in men and ~20% in women, whereas ~15% of men and ~5% of women may suffer from MD. Further identified related problems in military populations were excessive bodybuilding, the use of anabolic drugs, the intake of stimulants, weight and shape concerns, and weight-control behaviours. CONCLUSIONS BDD, MD, as well as the use of anabolic and stimulating drugs, are highly prevalent in military personnel. Despite the importance of these problems in the military, there are no military-specific treatment studies available. A pre-existing focus on physical appearance and fitness might contribute to the decision to pursue a professional military career. The military environment might be a maintaining factor of BDD or MD, but not the ultimate cause of the disorder in an affected individual.
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Affiliation(s)
- Briana Applewhite
- Department of Psychological Medicine, King's College London, London, UK
| | - M Olivola
- Department of Brain and Behavioural Science, University of Pavia, Pavia, Italy
- Department of Mental Health and Dependence, Azienda Socio-Sanitaria Territoriale di Pavia, Pavia, Italy
| | - C Tweed
- Eating Disorders Service, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Naval Medicine, Royal Navy, Gosport, UK
| | - U Wesemann
- Department of Psychiatry, Psychotherapy and Psychotraumatology, Bundeswehrkrankenhaus Berlin, Berlin, Germany
| | - H Himmerich
- Department of Psychological Medicine, King's College London, London, UK
- Eating Disorders Service, South London and Maudsley NHS Foundation Trust, London, UK
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Rautio D, Andrén P, Gumpert M, Jolstedt M, Jassi A, Krebs G, Jansson-Fröjmark M, Lundgren T, Serlachius E, Mataix-Cols D, Fernández de la Cruz L. Therapist-guided, Internet-delivered cognitive behaviour therapy for adolescents with body dysmorphic disorder: A feasibility trial with long-term follow-up. Internet Interv 2023; 34:100688. [PMID: 38034863 PMCID: PMC10685040 DOI: 10.1016/j.invent.2023.100688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/21/2023] [Accepted: 10/27/2023] [Indexed: 12/02/2023] Open
Abstract
Body dysmorphic disorder (BDD) is a prevalent and impairing psychiatric condition that typically debuts in adolescence and is associated with risky behaviours. The disorder can be effectively treated with cognitive behaviour therapy (CBT). However, CBT for BDD is seldom available primarily due to a shortage of trained therapists. Internet-delivered CBT (ICBT) can be a way to increase treatment availability. The aim of this feasibility trial was to evaluate the feasibility, safety, and preliminary efficacy of a CBT protocol for adolescents with BDD, adapted to be delivered over the Internet with minimal therapist support. A total of 20 participants (12-17-year-olds) meeting criteria for BDD were recruited nationally to a specialist outpatient clinic in Stockholm, Sweden. One participant withdrew consent and their data could not be analysed. Nineteen participants were offered 12 modules of therapist-guided ICBT for BDD and were followed up to 12 months post-treatment. Preliminary efficacy was measured at the a priori primary endpoint (3-month follow-up) and at the 12-month follow-up with the clinician-rated Yale-Brown Obsessive Compulsive Scale Modified for BDD for Adolescents. The treatment was rated as both credible and satisfactory and was associated with a large and statistically significant reduction in BDD symptom severity (d = 2.94). The proportion of participants classified as responders at the primary endpoint was 73.7%, and the proportion of full or partial remitters was 63.2%. The average therapist support time was 8 min per participant per week. Treatment gains continued to accrue up to the 12-month follow-up. Two participants attempted suicide and another two reported non-suicidal self-injuries during the study period. ICBT with minimal therapist support is a feasible, potentially efficacious, and durable treatment for adolescents with BDD. Risky behaviours typical of this patient group should be carefully monitored during treatment.
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Affiliation(s)
- Daniel Rautio
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Per Andrén
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Martina Gumpert
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Maral Jolstedt
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Amita Jassi
- National and Specialist OCD, BDD, and Related Disorders Clinic for Young People, South London and Maudsley NHS Foundation Trust, London, England, United Kingdom
| | - Georgina Krebs
- National and Specialist OCD, BDD, and Related Disorders Clinic for Young People, South London and Maudsley NHS Foundation Trust, London, England, United Kingdom
- University College London, Research Department of Clinical, Educational and Health Psychology, London, England, United Kingdom
| | - Markus Jansson-Fröjmark
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Tobias Lundgren
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Eva Serlachius
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Lorena Fernández de la Cruz
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
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Schoenenberg K, Bosbach K, Baumeister H, Küchler AM, Hartmann AS, Harrer M, Ebert DD, Martin A. Internet-Based Treatment of Body Dysmorphic Disorder: Feasibility, Evaluation, and Self-Report Data. J Nerv Ment Dis 2023; 211:686-695. [PMID: 37639458 DOI: 10.1097/nmd.0000000000001693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
ABSTRACT Initial findings indicate the effectiveness of internet-based interventions for body dysmorphic disorder (BDD). In order to substantiate these findings, a seven-module guided internet-based intervention was created and examined. We report the mixed data of participants with clinical and subclinical BDD of the treatment group (n = 18). We investigated the feasibility, the quality of the program content, the design and usability, and its effects on symptom severity and related psychopathology. Adherence to the intervention was low and dropout rate high (55.6%). The program content, perceived website usability, and visual aesthetic were rated high. Credibility and expectancy were on a medium level. Satisfaction with appearance improved significantly in the intention-to-treat analysis (d = 0.58). In sum, symptom-related outcomes and program evaluation showed a positive trend albeit the study conduction was difficult. Future programs should investigate the role of additional motivation strategies and more flexible support addressing the known treatment barriers.
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Affiliation(s)
- Katrin Schoenenberg
- Clinical Psychology and Psychotherapy, University Wuppertal, Wuppertal, Germany
| | - Katharina Bosbach
- Clinical Psychology and Psychotherapy, University Wuppertal, Wuppertal, Germany
| | | | | | | | | | - David Daniel Ebert
- Psychology and Digital Mental Health, Technical University Munich, Munich, Germany
| | - Alexandra Martin
- Clinical Psychology and Psychotherapy, University Wuppertal, Wuppertal, Germany
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Lundström L, Flygare O, Ivanova E, Mataix-Cols D, Enander J, Pascal D, Chen LL, Andersson E, Rück C. Effectiveness of Internet-based cognitive-behavioural therapy for obsessive-compulsive disorder (OCD-NET) and body dysmorphic disorder (BDD-NET) in the Swedish public health system using the RE-AIM implementation framework. Internet Interv 2023; 31:100608. [PMID: 36852382 PMCID: PMC9958485 DOI: 10.1016/j.invent.2023.100608] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/02/2023] [Accepted: 02/10/2023] [Indexed: 02/17/2023] Open
Abstract
Objectives Therapist-guided internet-delivered cognitive behaviour therapy (ICBT) is an efficacious treatment for obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD), but it is unclear if the results obtained in controlled trials can be reproduced in clinical settings. We evaluated the implementation of ICBT for OCD (OCD-NET) and BDD (BDD-NET) in the Swedish public health system. Methods Consecutive referrals to an outpatient psychiatric clinic providing ICBT, with a primary diagnosis of OCD or BDD, were included in the study. Four hundred and thirty-four participants started OCD-NET and 163 started BDD-NET. The primary outcome measures were the Yale Brown Obsessive Compulsive Scale (Y-BOCS) and the Y-BOCS for BDD (BDD-YBOCS), respectively. Participants were assessed before treatment, weekly during treatment, and after treatment. The study used the RE-AIM implementation framework, and the elements of reach, effectiveness, adoption, and implementation for the evaluation. Results Intention to treat analysis of the OCD-NET sample (n = 434) showed a significant decrease in OCD symptoms from pre-treatment to post-treatment (mean reduction = -8.77 [95 % CI -9.48 to -8.05] p < .001, d = 1.94 [95 % CI 1.75 to 2.13]). Forty-nine percent (95 % CI 43 % to 56 %) of the participants in OCD-NET were classified as treatment responders and 21 % (95 % CI 16 % to 27 %) were in remission. Participants in BDD-NET (n = 163) also showed a significant decrease in BDD symptoms from pre-post treatment (mean reduction = -11.37 [95 % CI -12.9 to -9.87] p < .001, d = 2.07 [95 % CI 1.74 to 2.40]) and 69 % (95 % CI 58 % to 79 %) of the participants were classified as treatment responders and 48 % (95 % CI 38 % to 58 %) were in full or partial remission. Eighty-seven percent of the participants in OCD-NET and 78 % in BDD-NET were treatment completers and participants in both treatment groups reported a high treatment satisfaction at post treatment (OCD-NET = 87 %, BDD-NET = 79 %). The most reported negative effects attributed to the treatments were transient experiences of unpleasant feelings (52 %) and anxiety (50 %). The implementation also influenced treatment delivery and dramatically decreased the mean number of patients waiting to receive face-to-face treatment at the clinic. Conclusions Our results indicate that OCD-NET and BDD-NET are suitable treatments for implementation in a Swedish public health service.
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Affiliation(s)
- Lina Lundström
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, SE-141 86 Stockholm, Sweden,Corresponding author at: Karolinska Institutet, M46, SE-14186 Huddinge, Sweden.
| | - Oskar Flygare
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
| | - Ekaterina Ivanova
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, SE-113 30 Stockholm, Sweden,Stockholm Health Care Services, Region Stockholm, CAP Research Centre, Gävlegatan 22, SE-113 30 Stockholm, Sweden
| | - Jesper Enander
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
| | - Diana Pascal
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
| | - Long-Long Chen
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
| | - Erik Andersson
- Department of Clinical Neuroscience, Division of Psychology, Nobels väg 9, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Christian Rück
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
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Flygare O, Andersson E, Glimsdal G, Mataix-Cols D, Pascal D, Rück C, Enander J. Cost-effectiveness of internet-delivered cognitive behaviour therapy for body dysmorphic disorder: Results from a randomised controlled trial. Internet Interv 2023; 31:100604. [PMID: 36756354 PMCID: PMC9900508 DOI: 10.1016/j.invent.2023.100604] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/05/2023] [Accepted: 01/22/2023] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To evaluate the cost-effectiveness of internet-delivered cognitive behaviour therapy for body dysmorphic disorder (BDD-NET). DESIGN Secondary cost-effectiveness analysis from a randomised controlled trial on BDD-NET versus online supportive psychotherapy. SETTING Academic medical center. PARTICIPANTS Self-referred adult participants with a primary diagnosis of body dysmorphic disorder and a score of 20 or higher on the modified Yale-Brown Obsessive Compulsive Scale for BDD (n = 94). Patients receiving concurrent psychotropic drug treatment were included if the dose had been stable for at least two months. INTERVENTIONS Participants received either BDD-NET (n = 47) or online supportive psychotherapy (n = 47) for 12 weeks. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measures were cost-effectiveness and cost-utility from a societal perspective, using remission status from a diagnostic interview and quality-adjusted life years (QALY), respectively. Secondary outcome measures were cost-effectiveness and cost-utility from a health care perspective and the clinic's perspective. RESULTS Compared to supportive psychotherapy, BDD-NET produced one additional remission for an average societal cost of $4132. The cost-utility analysis showed that BDD-NET generated one QALY to an average cost of $14,319 from a societal perspective. CONCLUSIONS BDD-NET is a cost-effective treatment for body dysmorphic disorder, compared to online supportive psychotherapy. The efficacy and cost-effectiveness of BDD-NET should next be directly compared to in-person cognitive behaviour therapy. TRIAL REGISTRATION NCT02010619.
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Affiliation(s)
- Oskar Flygare
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden,Corresponding author at: M46, Karolinska University Hospital, SE-141 86 Huddinge, Sweden.
| | - Erik Andersson
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - Gjermund Glimsdal
- Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden
| | - Diana Pascal
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden
| | - Christian Rück
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden
| | - Jesper Enander
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, and Stockholm Health Care Services, Region Stockholm, Sweden
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Telephone-Administered Cognitive Behavioral Therapy for Body Dysmorphic Disorder: Case Series. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127373. [PMID: 35742621 PMCID: PMC9223749 DOI: 10.3390/ijerph19127373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/12/2022] [Accepted: 06/15/2022] [Indexed: 02/04/2023]
Abstract
Cognitive behavioral therapy is an effective treatment for body dysmorphic disorder (BDD), but many patients do not receive appropriate treatment due to several treatment barriers and psychosocial care structures. Low-threshold interventions, including those from the field of e-mental health, could improve access to psychotherapy. In addition to internet-administered therapy, telephone-administered therapy may reduce treatment barriers, especially during the COVID-19 pandemic. This article presents four case reports of the same treatment (12 weeks of telephone-administered cognitive behavioral therapy accompanied by a workbook) applied to patients with body dysmorphic disorder during the summer of 2020. Three patients who completed the treatment had clinically relevant reductions in body dysmorphic and depressive symptoms and improved insight. One patient did not complete the telephone-administered therapy because her symptoms worsened, and she needed a more intensive form of treatment. These findings encourage future studies on the efficacy and effectiveness of telephone-administered treatment for BDD and its role in stepped-care models.
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A smartphone app for the prevention and early intervention of body dysmorphic disorder: Development and evaluation of the content, usability, and aesthetics. Internet Interv 2022; 28:100521. [PMID: 35281703 PMCID: PMC8907679 DOI: 10.1016/j.invent.2022.100521] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/23/2022] Open
Abstract
Body dysmorphic disorder (BDD) is an impairing condition characterized by excessive appearance concerns that frequently begin in adolescence, thus making this phase an eminent target for prevention and early intervention. We developed a cognitive-behavioral app-based program (AINA) intended for prevention and early intervention of BDD. As part of the iterative development process, perceptions of usability, aesthetics, and content were investigated. A sample of 38 adolescents and young adults aged between 14 and 21 years tested the app in a laboratory setting and completed a survey of diagnostic and user experience questionnaires. Overall, usability, aesthetics, and content of the app received positive evaluations. Regression analyses did not point to any large effects of age, gender, years of education, self-esteem, or BDD symptom severity on user evaluations. On average, participants had no concerns about privacy or data security of the app, indicating that these aspects will presumably not act as barriers to usage. Altogether, the present results are encouraging. Future research needs to examine whether AINA is an efficacious measure for prevention and early intervention of BDD.
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Drüge M, Buhlmann U, Dietel F, Hansmeier J, Jäger A, Dworakowski O, Rück C, Enander J, Watzke B. BDD-NET – Ein internetbasiertes Programm bei Körperunzufriedenheit zur niedrigschwelligen Behandlung der körperdysmorphen Störung für den deutschen Sprachraum. VERHALTENSTHERAPIE 2021. [DOI: 10.1159/000520345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Hintergrund: Die Körperdysmorphe Störung (KDS) ist eine schwerwiegende psychische Störung, die mit starker Scham sowie Leidensdruck und Funktionseinschränkungen einhergeht. Kognitive Verhaltenstherapie stellt die aktuell wirksamste evidenzbasierte Behandlungsmethode dar. Aufgrund zahlreicher Behandlungsbarrieren kommen KDS-Betroffene jedoch selten in der psychotherapeutischen Behandlung an, weshalb niedrigschwelligen Behandlungsmethoden (z.B. aus dem Bereich E-Mental-Health) eine wichtige Rolle zukommen könnten. Erste internationale Studien weisen auf die Wirksamkeit von E-Mental-Health-Angeboten bei KDS hin. Material und Methoden: Dieser Beitrag gibt eine Übersicht zur bisherigen Umsetzung und Evidenz von E-Mental-Health-Angeboten für KDS und stellt die ins Deutsche übersetzte Version des BDD-NET-Programms, eines internetbasierten, manualisierten, therapeutenbegleiteten Interventionsprogramms, für die KDS vor, welches aus dem Englischen für den deutschen Sprachraum übersetzt und adaptiert wurde. Ergebnisse: BDD-NET umfasst acht Module, die binnen einer 12-wöchigen Behandlung online bearbeitet werden. Die Online-Plattform bietet für die Patienten die Möglichkeit, mit dem BDD-NET-Therapeuten mittels persönlicher Nachrichten zu kommunizieren. Sämtliche Materialien wurden aus dem Englischen übersetzt und vor allem in kultureller Hinsicht adaptiert. Schlussfolgerungen: BDD-NET könnte ein wichtiger Baustein in der Versorgung von KDS-Betroffenen sein. Die Evaluation steht für den deutschen Sprachraum noch aus. Auf Besonderheiten des Settings (z.B. Störungseinsicht als möglicher Behandlungsfokus) sowie praktische Implikationen wird eingegangen. Zudem werden Voraussetzungen und Rahmenbedingungen für eine perspektivische Dissemination diskutiert.
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Reddy YCJ, Arumugham SS, Balachander S. Cognitive-behavioral and related therapies for obsessive-compulsive and related disorders. Curr Opin Psychiatry 2021; 34:467-476. [PMID: 34292182 DOI: 10.1097/yco.0000000000000731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Cognitive behavioral therapy (CBT) with exposure and response prevention is the first-line treatment for obsessive-compulsive disorder (OCD) and related disorders such as body dysmorphic disorder (BDD). We review here recent developments in CBT and related therapies in treating OCD and related disorders. RECENT FINDINGS Superiority of CBT over medications in treating OCD is being questioned by some recent meta-analyses, nonetheless CBT continues to be the mainstay of treatment. Web-based therapies have been shown to be beneficial in treating at least mild-to-moderately ill patients. Mindfulness-based CBT, intensive residential treatment and Bergen 4-day concentrated exposure are also proving to be useful in treating OCD. Large well designed studies have demonstrated the efficacy CBT over supportive therapy in treating BDD. Research on the efficacy of CBT in treating hoarding disorder is accumulating. SUMMARY Efficacy of web-based CBT has a potential public health importance in that CBT may now become accessible to all and benefit at least mild-to-moderately ill patients who form most of the clinically ill sample. Similarly, efficacy of Bergen 4-day concentrated exposure will have a huge public health implication if the findings can be replicated in other centers across the world.
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Affiliation(s)
| | | | - Srinivas Balachander
- Obsessive-Compulsive Disorder (OCD) Clinic
- Accelerator Program for Discovery in Brain Disorders Using Stem Cells (ADBS)
- Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India
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Flygare O, Chen LL, Fernández de la Cruz L, Rück C, Andersson E, Enander J, Mataix-Cols D. Empirically Defining Treatment Response and Remission in Body Dysmorphic Disorder Using a Short Self-Report Instrument. Behav Ther 2021; 52:821-829. [PMID: 34134823 DOI: 10.1016/j.beth.2020.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 11/15/2022]
Abstract
Determining response or remission status in body dysmorphic disorder (BDD) usually requires a lengthy interview with a trained clinician. This study sought to establish empirically derived cutoffs to define treatment response and remission in BDD using a brief self-report instrument, the Appearance Anxiety Inventory (AAI). Results from three clinical trials of BDD were pooled to create a sample of 123 individuals who had received cognitive-behavioral therapy for BDD, delivered via the Internet. The AAI was compared to gold-standard criteria for response and remission in BDD, based on the clinician-administered Yale-Brown Obsessive Compulsive Scale, modified for BDD (BDD-YBOCS), and evaluated using signal detection analysis. The results showed that a ≥ 40% reduction on the AAI best corresponded to treatment response, with a sensitivity of 0.71 and a specificity of 0.84. A score ≤ 13 at posttreatment was the optimal cutoff in determining full or partial remission from BDD, with a sensitivity of 0.75 and a specificity of 0.88. These findings provide benchmarks for using the AAI in BDD treatment evaluation when resource-intensive measures administered by clinicians are not feasible.
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Affiliation(s)
- Oskar Flygare
- Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services.
| | - Long-Long Chen
- Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services
| | | | - Christian Rück
- Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services
| | - Erik Andersson
- Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services
| | - Jesper Enander
- Centre for Psychiatry Research, Karolinska Institutet and CAP Research Centre, Stockholm Health Care Services
| | - David Mataix-Cols
- Centre for Psychiatry Research, Karolinska Institutet and CAP Research Centre, Stockholm Health Care Services
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Weingarden H, Hoeppner SS, Snorrason I, Greenberg JL, Phillips KA, Wilhelm S. Rates of remission, sustained remission, and recurrence in a randomized controlled trial of cognitive behavioral therapy versus supportive psychotherapy for body dysmorphic disorder. Depress Anxiety 2021; 38:10.1002/da.23148. [PMID: 33724643 PMCID: PMC8443701 DOI: 10.1002/da.23148] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/19/2021] [Accepted: 03/02/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Little data exist on remission rates following psychotherapy for body dysmorphic disorder (BDD). METHODS Using data from a large study of therapist-delivered cognitive behavior therapy (CBT) versus supportive psychotherapy (SPT) for BDD (N = 120), we estimated remission rates at treatment endpoint, and rates of delayed remission, sustained remission, and recurrence at 6-month follow-up. We also examined improvement in broader mental health outcomes among remitters. RESULTS Full or partial remission rates at end-of-treatment were significantly higher following CBT (68%) than SPT (42%). At 6-month follow-up, an additional 10% (CBT) and 14% (SPT) experienced delayed remission, 52% (CBT) and 27% (SPT) experienced sustained remission, and 20% (CBT) and 14% (SPT) experienced recurrence. Remission was never achieved by 18% (CBT) and 45% (SPT). Participants in remission at end-of-treatment experienced significant improvements in functional impairment, depression severity, BDD-related insight, and quality of life compared to nonremitters. CONCLUSIONS Full or partial remission rates are high following CBT for BDD and higher than after SPT.
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Affiliation(s)
- Hilary Weingarden
- Massachusetts General Hospital & Harvard Medical School, Boston, MA 02114
| | | | - Ivar Snorrason
- Massachusetts General Hospital & Harvard Medical School, Boston, MA 02114
| | | | - Katharine A. Phillips
- New York-Presbyterian Hospital and Weill Cornell Medical College
- Rhode Island Hospital and Alpert Medical School of Brown University
| | - Sabine Wilhelm
- Massachusetts General Hospital & Harvard Medical School, Boston, MA 02114
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Castle D, Beilharz F, Phillips KA, Brakoulias V, Drummond LM, Hollander E, Ioannidis K, Pallanti S, Chamberlain SR, Rossell SL, Veale D, Wilhelm S, Van Ameringen M, Dell’Osso B, Menchon JM, Fineberg NA. Body dysmorphic disorder: a treatment synthesis and consensus on behalf of the International College of Obsessive-Compulsive Spectrum Disorders and the Obsessive Compulsive and Related Disorders Network of the European College of Neuropsychopharmacology. Int Clin Psychopharmacol 2021; 36:61-75. [PMID: 33230025 PMCID: PMC7846290 DOI: 10.1097/yic.0000000000000342] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 10/13/2020] [Indexed: 11/25/2022]
Abstract
Body dysmorphic disorder (BDD) is characterized by a preoccupation with a perceived appearance flaw or flaws that are not observable to others. BDD is associated with distress and impairment of functioning. Psychiatric comorbidities, including depression, social anxiety, and obsessive-compulsive disorder are common and impact treatment. Treatment should encompass psychoeducation, particularly addressing the dangers associated with cosmetic procedures, and may require high doses of selective serotonin reuptake inhibitors* (SSRI*) and protracted periods to establish full benefit. If there is an inadequate response to SSRIs, various adjunctive medications can be employed including atypical antipsychotics*, anxiolytics*, and the anticonvulsant levetiracetam*. However, large-scale randomized controlled trials are lacking and BDD is not an approved indication for these medications. Oxytocin* may have a potential role in treating BDD, but this requires further exploration. Cognitive-behavioural therapy has good evidence for efficacy for BDD, and on-line and telephone-assisted forms of therapy are showing promise. CBT for BDD should be customized to address such issues as mirror use, perturbations of gaze, and misinterpretation of others' emotions, as well as overvalued ideas about how others view the individual.
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Affiliation(s)
- David Castle
- Department of Psychiatry, University of Melbourne and St Vincent’s Hospital
| | | | - Katharine A. Phillips
- New York-Presbyterian Hospital and Professor of Psychiatry, Weill Cornell Medical College, New York, New York, USA
| | - Vlasios Brakoulias
- School of Medicine, Western Sydney University and Western Sydney Local Health District, Sydney, Australia
| | - Lynne M. Drummond
- National Services for OCD/BDD, SW London and St George’s NHS Trust, London, UK
| | - Eric Hollander
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Konstantinos Ioannidis
- Department of Psychiatry, University of Cambridge, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Stefano Pallanti
- Albert Einstein College of Medicine, Bronx, New York, USA
- Istituto di Neuroscienze University of Florence, Florence, Italy
| | - Samuel R. Chamberlain
- Department of Psychiatry, University of Southampton
- Southern Health NHS Foundation Trust, Southampton
- Department of Psychiatry, University of Cambridge
- Department of Psychiatry, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Susan L. Rossell
- Centre for Mental Health, Swinburne University and St Vincent’s Hospital, Melbourne, Australia
| | - David Veale
- Department of Psychology, King’s College London and the South London and Maudsley NHS Foundation Trust, London, UK
| | - Sabine Wilhelm
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Michael Van Ameringen
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Bernardo Dell’Osso
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Jose M. Menchon
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, University of Barcelona, Cibersam, Barcelona, Spain
| | - Naomi A. Fineberg
- Department of Clinical and Pharmaceutical Sciences, University of Hertfordshire and Hertfordshire Partnership University NHS Foundation Trust, Hatfield, UK
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Abstract
Deficient inhibitory control and difficulty resolving uncertainty are central in psychopathology. How these factors interact remains unclear. Initial evidence suggests that inducing inhibitory control improves resolution of uncertainty. This may occur only when participants overcome action tendencies, which are dominant tendencies to perform certain behaviors. Our study explored the links between inhibitory control and behavioral responses to uncertainty while manipulating action-tendencies’ strength. In three experiments, 132 undergraduates completed a task that combined induction of momentary changes in inhibitory control level (Stroop task), with responses to uncertainty (visual-search task). We manipulated action-tendencies’ strength by varying uncertainty proportions across experiments. Results indicated that momentary induction of inhibitory control improved resolution of high-uncertainty during mostly low-uncertainty trials but hampered resolution of low-uncertainty during mostly high-uncertainty trials. Identical inhibitory control induction did not affect resolution of uncertainty when uncertainty conditions were equalized. Participants’ subjective uncertainty measures were similar across experiments. Our results suggest that momentary inhibitory control induction modifies behavioral responses to uncertainty and selectively affects trials that require overcoming dominant action tendencies. These findings indicate a potentially unique and multifaceted relationship between inhibitory control and behavioral responses to uncertainty. Clinical implications for models of Obsessive-Compulsive Disorder and experimental implications to post-conflict processes are discussed.
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Treatment barriers, preferences and histories of individuals with symptoms of body dysmorphic disorder. Behav Cogn Psychother 2020; 49:582-595. [PMID: 33161929 DOI: 10.1017/s1352465820000843] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Individuals with mental health concerns face many barriers when accessing psychological treatment. Even when patients overcome these barriers, they often do not receive an evidence-based treatment. Although the current literature highlights these issues clearly across psychological disorders, the research is limited in relation to body dysmorphic disorder (BDD). AIM The aim of this study was to examine psychological treatment barriers, treatment delivery preferences and treatment histories of individuals with symptoms of BDD. METHOD A total of 122 participants with clinically significant BDD symptoms (94% female; mean age = 34.19 years, SD = 10.86) completed the cross-sectional study. RESULTS The most frequently reported barriers to accessing psychological treatment for individuals with BDD symptoms were the cost of treatment (41%) and the belief that the symptoms did not warrant treatment (36%). Although 69% of treatment-seeking participants reported previously receiving cognitive behavioural therapy (CBT) for BDD, only 13% of participants appeared to receive best-practice CBT. The preferred modality of future psychological treatment delivery was face-to-face treatment with a therapist once a week (63%), rather than accelerated or remote treatment approaches. CONCLUSIONS The study suggests that there are significant barriers to accessing CBT for BDD. Reducing these barriers, as well as increasing consumer mental health literacy, is required to improve treatment access and treatment outcomes for individuals with BDD.
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Bjureberg J, Enander J, Andersson E, Ivanov VZ, Rück C, Fernández de la Cruz L. Sudden Gains in Internet-Based Cognitive Behavior Therapy for Body Dysmorphic Disorder. Behav Ther 2020; 51:753-763. [PMID: 32800303 DOI: 10.1016/j.beth.2019.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/31/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Abstract
Sudden gains have been associated with better short- and long-term treatment outcomes in a number of psychiatric disorders. However, no studies to date have evaluated sudden gains in body dysmorphic disorder (BDD). We used data from a previous randomized controlled trial evaluating the efficacy of an Internet-based cognitive-behavior treatment (CBT) for BDD. The sample consisted of 47 adults diagnosed with BDD. We compared the treatment outcomes of sudden gainers vs. gradual gainers (i.e., treatment responders with no sudden gains) and non-sudden gainers (i.e., gradual gainers plus nonresponders) at posttreatment and 3, 12, and 24 months after the end of the treatment. Twelve (25.5%) participants experienced a sudden gain. Compared to non-sudden gainers and to gradual gainers, sudden gainers showed significantly larger improvements on the Yale-Brown Obsessive-Compulsive Scale modified for BDD at posttreatment (g = 1.23 and g = .91, respectively), and at 3-month (g = 1.23 and g = 1.00, respectively), 12-month (g = 1.12 and g = .91, respectively), and 24-month follow-up (g = 1.11 and g = .97, respectively). This translated into higher rates of treatment responders and remitters in the sudden gainers across all time points. The occurrence of sudden gains in Internet-based CBT for BDD is associated with favorable short- and long-term treatment outcomes. This suggests that a sudden improvement during the treatment could be a marker of good prognosis, while non-sudden-including gradual-gainers are more likely to need continued support or booster sessions. Early identification of patients who are not progressing as expected and subsequent tailoring of the delivered intervention has the potential to improve treatment outcomes in this group.
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Affiliation(s)
- Johan Bjureberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet; Stockholm Health Care Services, Stockholm County Council, Stockholm
| | - Jesper Enander
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet
| | - Erik Andersson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet
| | - Volen Z Ivanov
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet; Stockholm Health Care Services, Stockholm County Council, Stockholm
| | - Christian Rück
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet; Stockholm Health Care Services, Stockholm County Council, Stockholm
| | - Lorena Fernández de la Cruz
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet; Stockholm Health Care Services, Stockholm County Council, Stockholm.
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Predictors of remission from body dysmorphic disorder after internet-delivered cognitive behavior therapy: a machine learning approach. BMC Psychiatry 2020; 20:247. [PMID: 32429939 PMCID: PMC7238519 DOI: 10.1186/s12888-020-02655-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 05/05/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Previous attempts to identify predictors of treatment outcomes in body dysmorphic disorder (BDD) have yielded inconsistent findings. One way to increase precision and clinical utility could be to use machine learning methods, which can incorporate multiple non-linear associations in prediction models. METHODS This study used a random forests machine learning approach to test if it is possible to reliably predict remission from BDD in a sample of 88 individuals that had received internet-delivered cognitive behavioral therapy for BDD. The random forest models were compared to traditional logistic regression analyses. RESULTS Random forests correctly identified 78% of participants as remitters or non-remitters at post-treatment. The accuracy of prediction was lower in subsequent follow-ups (68, 66 and 61% correctly classified at 3-, 12- and 24-month follow-ups, respectively). Depressive symptoms, treatment credibility, working alliance, and initial severity of BDD were among the most important predictors at the beginning of treatment. By contrast, the logistic regression models did not identify consistent and strong predictors of remission from BDD. CONCLUSIONS The results provide initial support for the clinical utility of machine learning approaches in the prediction of outcomes of patients with BDD. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT02010619.
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Körperdysmorphe Störung und Körperunzufriedenheit. PSYCHOTHERAPEUT 2020. [DOI: 10.1007/s00278-020-00407-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gentile AJ, La Lima C, Flygare O, Enander J, Wilhelm S, Mataix-Cols D, Rück C. Internet-based, therapist-guided, cognitive-behavioural therapy for body dysmorphic disorder with global eligibility for inclusion: an uncontrolled pilot study. BMJ Open 2019; 9:e024693. [PMID: 30904854 PMCID: PMC6475214 DOI: 10.1136/bmjopen-2018-024693] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Cognitive-behavioural therapy (CBT) has been shown to be an effective treatment for body dysmorphic disorder (BDD), but access to treatment around the world is limited. One way to increase access is to administer CBT remotely via the internet. This study represents the first effort to remotely deliver a therapist-supported, internet-based CBT treatment with no restrictions on enrolment based on geographical location, and it aims to assess whether this treatment can be delivered safely across international borders, with outcomes comparable to previous BDD-NET trials. DESIGN Uncontrolled clinical trial. PARTICIPANTS Patients (n=32) in nine different countries were recruited primarily through internet advertisements. INTERVENTION BDD-NET is a 12-week treatment, consisting of eight treatment modules previously shown to be effective in a Swedish version. SETTING Therapists based at a single, secondary care centre in Sweden provided active guidance and feedback throughout the treatment via asynchronous electronic messages. MAIN OUTCOME MEASURE The clinician-administered Yale-Brown Obsessive Compulsive Scale for BDD (BDD-YBOCS). Symptom severity was assessed pretreatment, mid-treatment (6 weeks), post-treatment and at the 3-month follow-up. RESULTS There were significant improvements on BDD-YBOCS scores (F(3, 71.63)=31.79, p<0.001), that were maintained at 3-month follow-up. Mean differences from baseline in BDD-YBOCS scores were -8.12 (week 6), -12.63 (post-treatment) and -11.71 (3-month follow-up). 47% and 50% of participants were considered treatment responders at post-treatment and 3-month follow-up, respectively. Additionally, remission rates were 28% at post-treatment and 44% at 3-month follow-up. The treatment was also deemed acceptable by patients. CONCLUSIONS The results suggest that BDD-NET can be safely and effectively delivered across international borders to a culturally diverse sample. Larger scale randomised controlled trials with more participants from non-Western cultures are warranted to further validate the cross-cultural generalisability of this treatment. TRIAL REGISTRATION NUMBER NCT03517384.
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Affiliation(s)
- Andrew J Gentile
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Christopher La Lima
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Oskar Flygare
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Jesper Enander
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Sabine Wilhelm
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Mataix-Cols
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Christian Rück
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
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