Efficacy and Posttreatment Effects of Therapist-Delivered Cognitive Behavioral Therapy vs Supportive Psychotherapy for Adults With Body Dysmorphic Disorder: A Randomized Clinical Trial
Open accessAbstract
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.
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Specific CBT techniques such as exposure and response prevention, mirror retraining, and cognitive restructuring are highly effective in modifying the negative self-perceptions that drive BDD symptoms.
“Specific techniques, such as exposure and response prevention (ERP), mirror retraining, and cognitive restructuring, are highly effective in modifying the negative self-perceptions that drive BDD symptoms [121].”
From The Impact of Social Media & Technology on Child and Adolescent Mental Health (2025) · cites this paper as [121]
The “Cognitive Behavioral Therapy for Body Dysmorphic Disorder” section (page not available) lists exposure and ritual prevention and cognitive restructuring, and describes strategies intended to modify appearance-related assumptions. It does not mention mirror retraining. The Results (page not available) show improvement with the CBT package, but do not establish that these individual techniques are highly effective at modifying negative self-perceptions; CBT’s advantage over supportive psychotherapy also varied by site. (LLM, conf=0.88)
Experimental — accuracy not yet measuredIndividuals with BDD are more likely to seek cosmetic or dermatological procedures rather than psychiatric intervention.
“Furthermore, individuals with BDD are more likely to seek cosmetic or dermatological procedures rather than psychiatric intervention, which can exacerbate symptoms and increase distress when the perceived flaws remain uncorrected [121].”
From The Impact of Social Media & Technology on Child and Adolescent Mental Health (2025) · cites this paper as [121]
The Cognitive Behavioral Therapy for Body Dysmorphic Disorder section (page unavailable) identifies seeking surgical intervention as a symptom that may require a treatment module. It does not say that people with BDD seek cosmetic or dermatological procedures more often than psychiatric care, or that such procedures worsen symptoms or distress. (LLM, conf=0.76)
Experimental — accuracy not yet measuredSeeking cosmetic or dermatological procedures can exacerbate BDD symptoms and increase distress when the perceived flaws remain uncorrected.
“Furthermore, individuals with BDD are more likely to seek cosmetic or dermatological procedures rather than psychiatric intervention, which can exacerbate symptoms and increase distress when the perceived flaws remain uncorrected [121].”
From The Impact of Social Media & Technology on Child and Adolescent Mental Health (2025) · cites this paper as [121]
The Cognitive Behavioral Therapy for Body Dysmorphic Disorder section identifies seeking surgical intervention as a symptom that treatment may target. It does not say that people with BDD seek cosmetic or dermatological procedures more often than psychiatric care, or that such procedures exacerbate symptoms or distress when perceived flaws remain uncorrected. (LLM, conf=0.78)
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References 49 · Cited by 99
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- Authors
- Wilhelm, S., Phillips, K. A., Greenberg, J. L., O’Keefe, S. M., Hoeppner, S. S., Keshaviah, A., Sarvode-Mothi, S., & Schoenfeld, D. A.
- Affiliations
- Harvard University (US)
- NewYork–Presbyterian Hospital (US)
- Mathematica Policy Research (US)
- Massachusetts General Hospital (US)
- Corresponding author
- Wilhelm, Sabine
- ORCID
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2019-04-01
- Volume
- 76
- Issue
- 4
- Pages
- 363
- ISSN
- 2168-622X (ISSN-L)
- PMC
- PMC6450292
- OpenAlex
- W2917305441
- Cited by
- 99
- References
- 49
- Citations by year
- 2026: 10 · 2025: 9 · 2024: 24 · 2023: 16 · 2022: 16 · 2021: 12 · 2020: 9 · 2019: 3
- FWCI
- 11.68
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Psychiatry (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute of Mental Health (R01MH091023, R01MH091078)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Body Image and Dysmorphia Studies
- Social Sciences › Psychology › Clinical Psychology › Obsessive-Compulsive Spectrum Disorders
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- body dysmorphic disorder, cognitive behavioral therapy, supportive therapy, treatment efficacy, treatment durability, depressive symptoms, functional disability, quality of life, insight, psychoeducation, self-esteem, obsessive-compulsive symptoms, treatment acceptability
- MeSH terms
- Adult, Female, Humans, Male, Psychotherapy, Cognitive Behavioral Therapy, Treatment Outcome, Body Dysmorphic Disorders
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