Abstract
Although cognitive-behavioral therapy (CBT) is highly efficacious for body dysmorphic disorder (BDD), not all patients benefit, and mechanisms underlying response remain unknown. In this first report of the mechanisms underlying improvement with CBT for BDD, we examined whether cognitive (maladaptive beliefs, perfectionism, schemas) and behavioral (checking, grooming, avoidance behaviors) changes mediate the effect of CBT on BDD symptom reduction. Forty-five participants with BDD who enrolled in a CBT for BDD treatment development study were included in two sets of analyses: (1) between-subject mediation of the effect of 12 weeks of CBT versus waitlist, and (2) within-subject mediation of longitudinal change in BDD symptom severity during 24 weeks of CBT. No significant mediators emerged in the between-subject analysis. Checking, grooming, avoidance behaviors, and maladaptive beliefs mediated within-subject improvements over time. Findings suggest that BDD symptom reduction occurs through the very mechanisms that have been hypothesized to maintain BDD in CBT models. Targeting certain cognitive (beliefs about appearance) and behavioral (checking, grooming, and avoidance behaviors) mechanisms in future treatment trials may enhance symptom improvement during CBT.
National Clinical Trials Registration Identifier # NCT00106223.
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Notes
It is worth noting that, although using pre- (week 0) and post- (week 24) treatment scores ignores the additional data points collected for the mediator over the course of treatment, we used this methodology instead of a linear growth curve model (to estimate individual slopes for each participant using all available data points) because the relationship between the outcome (BDD-YBOCS) and mediators was non-linear.
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Acknowledgements
We would like to acknowledge the following individuals for their assistance in conducting the study and preparing the manuscript: Valerie Braddick, Ulrike Buhlmann, Hillary Cerullo, Katherine Crowe, Eliza Davidson, Sherrie Delinsky, Natasha Hansen, Irina Kasarskis, Luana Marques, William Menard, Jennifer Ragan, Stefanie Renaud, Tracy Singer, Angela Stewart, and Kara Watts.
Funding
This work was supported by the National Institute of Mental Health (Grant Numbers R34 MH070490, K23 MH109593, and K24MH063975), and the Neil and Anna Rasmussen Research Fund.
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Dr. Steketee has the following disclosure to report: Guilford Press (royalties). Dr. Phillips has the following disclosures to report: Oxford University Press/International Creative Management, Inc. (book royalties); UpToDate/Wolters Kluwer (writing royalties); Guilford Press (book royalties), Merck Manual (book chapter honorarium); Aesculap Academia (B. Braun Medical Limited) (travel reimbursement for presentations at a professional meeting); Oakstone Publishing (presentation honorarium); and speaking honoraria and/or travel reimbursement from academic institutions and professional organizations. Dr. Wilhelm has the following disclosures to report: Forest Laboratories (free medication and matching placebo for clinical trials funded by the NIH); Massachusetts General Hospital Psychiatry Academy (educational programs supported through independent medical education grants from pharmaceutical companies); Elsevier Publications, Guilford Publications, New Harbinger Publications, and Oxford University Press (royalties); speaking honoraria from various academic institutions and foundations, including the International Obsessive Compulsive Disorder Foundation and the Tourette Association of America; Association for Behavioral and Cognitive Therapies (payment for her role as Associate Editor for the Behavior Therapy journal) and John Wiley & Sons, Inc. (Associate Editor on the journal Depression & Anxiety); Novartis (salary support). The other co-authors declare that they have no conflicts of interest.
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Fang, A., Steketee, G., Keshaviah, A. et al. Mechanisms of Change in Cognitive Behavioral Therapy for Body Dysmorphic Disorder. Cogn Ther Res 44, 596–610 (2020). https://doi.org/10.1007/s10608-020-10080-w
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DOI: https://doi.org/10.1007/s10608-020-10080-w